A 44-year-old man without a past medical history presented to the cardiology department with complaints of shortness of breath on exertion for about a few weeks.
An upper respiratory tract infection without fever or chest pain preceded the symptoms.
He had a burdening family history of sudden cardiac deaths at a young age.
In an echo exam, a large aneurysm of ascending aorta with a diameter of 9.3 centimetres was revealed. All heart chambers were enlarged with a reduced global left ventricular ejection fraction of 35%. A severe regurgitation of the tricuspid aortic valve was demonstrated. Moreover, a severe tricuspid regurgitation observed, as well as moderate mitral regurgitation. Computed tomography with contrast had been performed, and aortic dissection had been excluded. No significant coronary artery narrowing was found.
An intensive pharmacotherapy for heart failure was implemented. The patient also underwent Bentall’s successful surgery with mitral annuloplasty using the Edwards Physio 36 mm ring and tricuspid annuloplasty using the Edwards MC3 36 mm ring additionally.
Echocardiographic follow-up revealed good Masters HP Valved Graft function, moderate mitral regurgitation, and mild tricuspid regurgitation. Due to the persistent left ventricular enlargement and systolic function worsening with an ejection fraction of 23% despite optimal pharmacological treatment of heart failure, the patient required implantation of a cardioverter-defibrillator for primary prevention of sudden cardiac death.
Additionally, an endomyocardial biopsy of the right and left ventricles was performed, revealing histological and immunohistochemical chronic active myocarditis evidence.1,2 After excluding viral background, the patient was scheduled to start steroids and immunosuppressive drugs, including azathioprine.
The patient remains asymptomatic at the 1-year follow-up.
This case demonstrated that an initial diagnosis of heart failure may not be sufficient. Identifying the primary causal mechanism of heart damage is fundamental to correctly implementing further diagnostic and therapeutic strategies for improving patients’ prognoses (Figure 1).
Figure 1.
(A–D) Multimodality images (transthoracic echocardiography and computed tomography scans) of an ascending aortic aneurysm. (E) Masson’s trichrome staining reveals interstitial and replacement fibrosis fibrosis and the concomitant presence of focal myocardial necrosis. (F) Endomyocardial biopsy tissue showing CD3 (+) lymphocytes (arrows) located in the interstitial space.
Contributor Information
Agnieszka Dębska-Kozłowska, Department of Interventional Cardiology, Medical University of Lodz, 251 Pomorska Street, Lodz 92-213, Poland.
Karolina Supeł, Department of Interventional Cardiology, Medical University of Lodz, 251 Pomorska Street, Lodz 92-213, Poland.
Romuald Wojnicz, Department of Histology and Cell Pathology & Silesian Nanomicroscopy Center in Zabrze, Medical University of Silesia in Katowice, 19 Jordana Street, Katowice 41-808, Poland.
Marzenna Zielińska, Department of Interventional Cardiology, Medical University of Lodz, 251 Pomorska Street, Lodz 92-213, Poland.
Lead author biography
Agnieszka Dębska-Kozłowska is a specialist in internal medicine and cardiology with the title of Medical Doctor. She is currently a senior assistant at the Department of Interventional Cardiology at the Central Clinical Hospital of the Medical University of Lodz (Poland). She obtained the Individual Training Accreditation in echocardiography 2nd Degree of Echocardiography Section of Polish Society of Cardiology and EACVI Certification in Cardiological Magnetic Resonance. Her clinical and research interests focus on heart failure patients. She also has experience in managing adult patients with acute cardiac conditions. Additionally, she is a specialist of medical law and serves on Medical Court.
Author contributions
Agnieszka Debska-Kozlowska (Conceptualization, Project administration, Writing—original draft [lead], Visualization [equal]), Karolina Supel (Conceptualization [supporting], Visualization [equal]), Romuald Wojnicz (Data curation [supporting], Visualization [equal]), and Marzenna Zielinska (Supervision [equal])
Consent: A patient consent statement was obtained for the publication of materials concerning his medical history due to the requirements of EHJ Case Reports, confirming compliance with COPE guidelines.
Funding
None declared.
Data availability
The data underlying this article are available in the article.
References
- 1. Chimenti C, Frustaci A. Histopathology of myocarditis. Diagn Histopathol 2008;14:401–407. [Google Scholar]
- 2. Ammirati E, Buono A, Moroni F, Gigli L, Power JR, Ciabatti M, et al. State-of-the-art of endomyocardial biopsy on acute myocarditis and chronic inflammatory cardiomyopathy. Curr Cardiol Rep 2022;24:597–609. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data underlying this article are available in the article.