Figure 1.
Diagnosis and Management of a Patient With ICI-Induced Myocarditis and Cardiogenic Shock
(A) Timeline describing the patient’s clinical presentation, diagnostic findings, and treatment approach. *The patient was dependent on extracorporeal membrane oxygenation (ECMO) for 3 days, after which she was weaned from extracorporeal membrane oxygenation on the basis of hemodynamic improvement. †A total dose of 330 mg of antithymocyte globulin (ATG) was administered as divided doses over 5 days. ‡Mycophenolate mofetil (1,000 mg twice daily) was added on day 7 and continued for 1 month. §Guideline-directed medical therapy (GDMT) for heart failure (HF) was initiated and gradually titrated as the patient improved (Valsartan 80 mg twice daily which was switched on discharge to sacubitril-valsartan 49 to 51 mg twice daily, spironolactone 12.5m g increased to 25 mg once daily, and bisoprolol 1.25 mg daily, which was initiated upon discharge). (B) Endomyocardial biopsy and cardiac magnetic resonance in immune-checkpoint inhibitor (ICI)–induced myocarditis. (Left) Endomyocardial histological findings (hematoxylin and eosin stain) showing lymphocytic infiltration of the myocardium (asterisks) with surrounding eosinophils (arrow). (Right) Cardiac magnetic resonance, short-axis views showing midwall late gadolinium enhancement (arrows) in the basal and midsegmental inferolateral walls (left side) and myocardial edema on a T2 qualitative image (arrows) (right side). ECG = electrocardiogram; EMB = endomyocardial biopsy; hs-cTnT = high-sensitivity cardiac troponin; IABP = intra-aortic balloon pump; ICI = immune-checkpoint inhibitor; LVEF = left ventricular ejection fraction; NT-proBNP = N-terminal pro-B-type natriuretic peptide; NYHA = New York Heart Association (functional class); PVR = pulmonary vascular resistance; RV = right ventricle; RVSWI = right ventricular stroke work index; Rx = treatment; STE = ST-segment elevation; VT = ventricular tachycardia; WU = wood units.