PMC9934937_01
ECG and MRI findings of case 1.. (a) ECG showed sustained ventricular tachycardia and left bundle branch morphology with the superior axis. (b) MRI showed dilated RA/RV free wall dyskinesia with diffuse free wall enhancement on gadolinium contrasts.. RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle
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FIG1
ECG tracing was taken out, which shows sustained ventricular tachycardia and left bundle branch morphology with the superior axis (Figure 1a). Based on the above clinical findings, it made us think of right-sided cardiomyopathy for we planned to go for cardiac MRI, which shows a nondilated left ventricle with an ejection fraction of 55% and dilated RA/RV free wall dyskinesia with diffuse free wall enhancement on gadolinium contrasts (Figure 1b).
PMC9934937_02
ECG, 2D ECHO, and MRI findings of case 2.. (a) ECG showed frequent ventricular ectopy with incomplete RBBB morphology. (b) 2D ECHO showed the dilation of RA/RV with decreased right ventricular function. (c) MRI showed dilated RA/RV with right ventricular free wall dyskinesia. (d) MRI showed aneurysmal outpouching with diffuse free wall enhancement.. 2D ECHO, two-dimensional echocardiography; RBBB, right bundle branch block; RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle
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FIG2
The patient's ECG was taken that showed frequent ventricular ectopy with incomplete RBBB morphology (Figure 2a). A diagnosis of sick sinus syndrome seems to be likely, but during routine 2D ECHO examination, there was a dilation of RA/RV with decreased right ventricular function as TAPSE was 11 mm with associated right ventricle outflow tract obstruction (RVOTO) diameter of 40 mm and moderate low-pressure tricuspid regurgitation (right ventricular systolic pressure {RVSP}: 44 mm Hg), and the apical portion of right ventricular appears to be thinned out with akinesia in apical and free wall of right ventricles (Figure 2b). MRI was planned, which reveals dilated RA/RV with right ventricular free wall dyskinesia and aneurysmal outpouching with diffuse free wall enhancement; these cardiac MRI findings are suggestive of ARVD; based on the above findings, we approximate toward the diagnosis of ARVD as per Task Force criteria (2020) (Figure 2c-2d). Major focus was on the management part of the patients that can improve the quality of life and provide symptom-free states of syncope, non-sustained VT, and drugs for heart failure.
PMC9934937_03
ECG, 2D ECHO, and MRI findings of case 3.. (a) ECG showed frequent VPC with bigeminy, couplets, and T wave inversion in lead V1-V3 without RBBB. (b) 2D ECHO showed enlarged RA/RV with mild low-pressure tricuspid regurgitation. (c) MRI showed dilated right ventricle with RV dyskinesia/desynchrony. (d) MRI showed low-pressure tricuspid regurgitations.. 2D ECHO, two-dimensional echocardiography; VPC, ventricular premature contraction; RBBB, right bundle branch block; RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle; MB, mitral bulge
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FIG3
Frequent ECG tracing was taken, which showed frequent VPC with bigeminy, couplets, and T wave inversion in lead V1-V3 without RBBB (Figure 3a). A 24-hour Holter monitoring was planned, which does not reveal extra finding before and after the routine ECG. 2D ECHO was done, which showed enlarged RA/RV with mild low-pressure tricuspid regurgitation (RVSP: 25 mm Hg); right free wall looks relatively thinned out and hypokinetic, TAPSE was 14 mm, RVOTO dimension was 37 mm, and left ventricle ejection fraction (LVEF) was 58% by Simpsons methods (Figure 3b). With the above evidence of right-sided cardiomyopathy, we plan to go for cardiac MRI, which revealed dilated right ventricle with RV dyskinesia/desynchrony; right ventricle end diastolic volume index was 125 ml/m2, and right ventricle ejection fraction was 30% with cine evidence of low-pressure tricuspid regurgitations (Figure 3c-3d).
PMC9934937_04
ECG, 2D ECHO, and MRI findings of case 4.. (a) ECG showed ventricular tachycardia with LBBB and superior axis. (b) ECG showed the presence of T wave inversions in lead V1-V3 in the absence of complete RBBB and frequent premature ventricular rhythms. (c) 2D ECHO dilated RA and RV with normal right ventricular functions and moderate tricuspid regurgitation. (d) MRI showed outpouching of apical right ventricles with thinned right ventricle free wall and increased intensity of right ventricular free wall globally.. 2D ECHO, two-dimensional echocardiography; LBBB, left bundle branch block; RBBB, right bundle branch block; RVOT, right ventricle outflow tract; RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle
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FIG4
ECG was taken, which shows ventricular tachycardia with LBBB and superior axis (Figure 4a). The retrospective study of his previous ECG shows the presence of T wave inversions in lead V1-V3 in the absence of complete RBBB and frequent premature ventricular rhythms (Figure 4b). 2D ECHO was done, which shows dilated RA and RV with normal right ventricular functions (TAPSE of 22 mm with RVOTO diameter of 39 mm) and was also associated with moderate tricuspid regurgitation (RVSP: 54 mm Hg) (Figure 4c). Cardiac MRI shows outpouching of apical right ventricles with thinned right ventricle free wall and was also associated with increased intensity of right ventricular free wall globally (Figure 4d).
PMC9934937_05
MRI showed grossly deranged right ventricular function with outpouching and thinned out apical segment with late gadolinium enhancement of right ventricular free wall.. RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle
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FIG5
This might be a case of RV cardiomyopathy for which cardiac MRI was done, which grossly deranged right ventricular function (RV ejection fraction was 34%) with outpouching and thinned out apical segment with late gadolinium enhancement of right ventricular free wall (Figure 5).