PMC9120606_01
Brain magnetic resonance imaging. (A) Axial and (B,C) sagittal views in FLAIR sequence showing demyelinating lesions consistent with multiple sclerosis: perpendicular to the lateral ventricles (A), periventricular (B), and corpus callosum (C) (white arrows). (D) Twelve-lead electrocardiogram showing sinus tachycardia (125 beats/min), left atrial dilatation [P mitrale in II, and deepening of the terminal negative portion of the P wave in V1 (black arrows)] and left bundle branch block [QRS duration of >120 ms (blue arrow), lead V1 with a dominant deep S wave (green arrow); broad, notched R wave in V6 and I, and monophasic R wave in aVL (red arrows)]. ms, milliseconds.
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Her past medical history revealed a history of relapsing-remitting MS (Figures 1A-C) diagnosed 15 years ago and treated with azathioprine and prednisone. The electrocardiogram (ECG) showed sinus tachycardia and complete left bundle branch block (LBBB) (Figure 1D).
Transthoracic echocardiogram. (A) Parasternal short axis of the mid left ventricle demonstrating two-layer myocardial structure, with a ratio of ticker non-compacted (redline) to thin compacted (yellow line) myocardium >2 at end-systole in the inferolateral segment. (B) Flow between intertrabecular recesses by intraventricular blood on color Doppler (white arrows). (C) Reduced global longitudinal strain (-6.5%). (D) Two-chamber view showing a regional deformation pattern with a markedly decreased myocardial deformation in apical segments (green and purple curves) in comparison to basal segments (red and yellow curves). Coronary angiography: coronary arteries without lesions (E,F) (white arrows). LCA, left coronary artery; LCx, left circumflex coronary artery; LM, left main coronary artery; LV, left ventricle; RCA, right coronary artery.
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Transthoracic echocardiogram (TTE) demonstrated a left ventricular ejection fraction (LVEF) of 30%, mildly dilated, diffusely hypokinetic, prominent trabeculations of LV, and a non-compacted to compacted (NC/C) myocardium ratio of 2.75 in end-systole at inferolateral mid-ventricular level (Figures 2A-D), so the diagnosis of NCCM was realized. On the sixth hospital day, coronary angiography revealed that coronary arteries were normal (Figures 2E,F).
Cardiac MRI. (A) Short axis, (B) 4-chamber, and (C) 2-chamber views showing representative measurements of the ratio of ticker non-compacted (redlines) to thin compacted (yellow lines) myocardium >2.3 at end-diastole, in the (A) mid-inferolateral, (B) mid-anterolateral, and (A,C) mid-inferior segments. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.
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Cardiovascular magnetic resonance (CMR) imaging was performed 1 month after discharge to confirm the diagnosis and demonstrated positive diagnostic criteria for NCCM; additionally, the study did not show late gadolinium enhancement (LGE) (Figure 3).
The timeline of events. CMR, cardiac magnetic resonance; LV, left ventricle; LVEF, left ventricular ejection fraction; NC/C, non-compacted to compacted; NYHA, New York Heart Association; TTE, transthoracic echocardiogram.
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ADHF. A timeline is showcased in Figure 4.