PMC6633872_01
Electrocardiogram on admission. Electrocardiogram shows tachycardia, sinus rhythm, right axis deviation, nonspecific ST-T change, and clockwise rotation.
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The electrocardiogram revealed tachycardia, sinus rhythm, right axis deviation, nonspecific ST-T change, and clockwise rotation (Figure 1). The follow-up EMB, performed 2 weeks after his admission, revealed improved infiltration of eosinophils and lymphocytes and some degree of fibrosis (Supplementary Figure 1).
Findings on admission and after Impella placement. (a) Pre-Impella placement chest radiograph shows prominent pulmonary edema with an enlarged cardiac shadow. (b) At admission (pre-Impella placement), echocardiography, parasternal long-axis view, shows an extensively thickened left ventricle with enhanced echogenicity and a modest amount of pericardial effusion [left-ventricular ejection fraction (LVEF) 42%]. (c) Post-Impella placement chest radiography shows less pulmonary edema. (d) Post-Impella placement echocardiography, parasternal long-axis view, shows Impella inlet parts with an acoustic shadow in the proper position (yellow arrow) (LVEF 27%). (e) At discharge, chest radiography shows an almost normal cardiac shadow. (f) At discharge, echocardiography, parasternal long-axis view, shows improved contractility without pericardial effusion (LVEF 60%).
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His chest radiograph showed prominent pulmonary edema, accumulation of pleural effusion, and an enlarged cardiac shadow (Figure 2(a)). Echocardiography showed LV systolic dysfunction:LV end-diastolic volume (LVEDV) and end-systolic volume (LVESV) = 130/76 mL; LV ejection fraction (LVEF) 42%:a mildly thickened and echogenic LV wall, and a modest amount of pericardial effusion, without visible intraventricular thrombus (Figure 2(b)). Chest radiography after Impella placement showed alleviated pulmonary edema (Figure 2(c)) together with elevation of the mean arterial pressure from 51 to 72 mmHg, although the LVEF was decreased to 27% (Figure 2(d); Supplementary Movie 1). At discharge from the hospital, follow-up chest radiography revealed diminishing cardiomegaly with no pulmonary congestion (Figure 2(e)). At the same time echocardiography showed recovery of contractility with LVEF 60% (Figure 2(f)).
Histological findings of right-ventricular endomyocardial biopsy specimen on admission. Hematoxylin-eosin staining (formalin-fixed; paraffin-embedded) shows damaged myocardium and infiltration of degranulated eosinophils (arrow, right), lymphocytes, and neutrophils. (a) x20. (b) x60.
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Within 48 h after admission, eosinophilic myocarditis was diagnosed based on the histological findings (Figure 3).
Changes in blood markers during hospitalization. Graphs showing changes in serum troponin I and creatine-kinase concentrations, white blood cell and eosinophil counts, plasma brain natriuretic peptide, serum C-reactive protein, serum creatinine, and serum aspartate amino transferase concentrations, together timing of with mechanical circulatory support and immunosuppressive therapy. PVAD, percutaneous ventricular assist device; m-PSL, methyl-prednisolone; PSL, prednisolone.
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He was discharged from hospital 6 weeks after the admission without a major complication (Figure 4).
Thallium-201 and iodine-123 beta-methyl-p-iodophenylpentadecanoic acid dual-tracer myocardial scintigraphy 3 weeks after admission. Slight patchy deficit was found for myocardial thallium uptake in the anterolateral wall and further decreased uptake of BMIPP, which was consistent with a mild perfusion-metabolism mismatch (white arrows). (a) Long-axis 2D view. (b) Short axis 2D view. (c) Polar map. 2D, two-dimensional; ANT, anterior; INF, inferior; TL, thallium.
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Cardiac 1.5-T magnetic resonance imaging 4 weeks after admission. (a) T2-weighted black-blood images show no significant high-intensity signal. (b) Late-gadolinium enhancement shows no significant focal high-intensity signal. (c) Native T1 mapping analysis shows mildly elevated values: (1) anterior wall, 1193.01+-36.34 msec, (2) septal wall, 1193.05+-32.03 msec, and (3) posterolateral wall, 1198.87+-42.86 msec.
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