case_images: PMC8818743_01
case_images: (A) ECG for the woman patient when admitted to hospital: Sinus rhythm Right bundle branch block; (B) ECG of the man patient when admitted to hospital; V1-V3 lead ST-elevation and third-degree atrioventricular block; (C) ECG of the man patient when implanted with temporary pacing; (D) ECG of the man patient at discharge: Sinus rhythm, Right bundle branch block.
case_images: fcvm-08-769616-g0001.jpg
case_images: PMC8818743_02_fcvm-08-769616-g0001.jpg
case_images: F1
case_images: An emergency electrocardiogram revealed a third-degree atrioventricular block (AVB) (Figure 1B). Physical examination revealed a body temperature of 36.2 C, blood pressure of 101/60 mmHg, pulse of 77 bpm (pacemaker heart rate, Figure 1C), respiratory rate of 18 bpm, and blood oxygen saturation of 99% while the patient was breathing ambient air. After 9 days, the LVEF recovered to 59% with a normal sinus rhythm (Figure 1D) when he was discharged with oral beta-blockers (47.5 mg/day), perindopril (4 mg/day), and prednisone 20 mg/day.
case_images: Coronary angiography results for Case 1 (A-C): (A) Left coronary artery: Cranial 30 ; (B) Left coronary artery: Caudal 30 ; (C) Right coronary artery: Left anterior oblique 45 ; Coronary angiography results for Case 2 (D-F): (D) Left anterior oblique 30 + Cranial 30 ; (E) Left coronary artery: Caudal 30 ; (F) Right coronary artery: Left anterior oblique 45 .
case_images: fcvm-08-769616-g0002.jpg
case_images: PMC8818743_01_fcvm-08-769616-g0002.jpg
case_images: F2
case_images: Urgent coronary angiography excluded coronary artery disease (Figures 2A-C); therefore, transthoracic echocardiography (TTE) with strain analysis revealed diffuse left ventricular hypokinesia and increased thickness of the mid-ventricular septal wall (septal wall 13 mm; inferior wall 11 mm), and markedly reduced LV ejection fraction (LVEF 30%) (Figures 3B,D).
case_images: The echocardiographic and cardiac magnetic resonance images recorded at admission and the findings of pathological specimens compatible with fulminant myocarditis. (A) LV ejection fraction was mildly reduced (EF value, 28%); (B) LV ejection fraction was mildly reduced (EF value = 30%); (C) Representative images of global longitudinal strains (GLS) presented as "bullseye" displays in case 1 (GLS = -12.1%); (D) Representative images of global longitudinal strains (GLS) presented as "bullseye" displays in case 2 (GLS = -9.8%); (E) Increased myocardial signal in the outer layer of the apical ventricular septum (edema) (arrow); (F) Late gadolinium enhancement imaging suggests myocardial enhancement in the outer layer of the apical ventricular septum (myocardial necrosis) (arrow); (G) Long-axis late gadolinium enhancement imaging suggests myocardial necrosis in the middle ventricular septum (red arrow), thinning, and enhancement of the lateral wall (yellow arrow); (H) Short axial late gadolinium enhancement imaging demonstrates myocardial necrosis in the middle ventricular septum (red arrow) with thinning of the lateral wall and formation of fibrosis (yellow arrow); (I) in T1 mapping, ventricular septal myocardial edema was observed, and the value of myocardial T1 was significantly increased, T1=1380 ms (normal value T1 = 1,180 +- 20 ms); (J) Myocardial edema in the lower interventricular septum was observed in T1 mapping, and the value of myocardial T1 was significantly increased, T1 = 1,364 ms (normal value T1 = 1,180 +- 20 ms); (K) Biopsy from myocardium showing myocardial fibers were slightly edematous and interstitial edema was accompanied by infiltration of inflammatory cells; (L) Biopsy from myocardium showing myocardial atrophy, hypertrophy of some cardiomyocytes, myocardial interstitial edema, local fibrosis, scattered focal necrosis of cardiomyocytes accompanied by infiltration of inflammatory cells.
case_images: fcvm-08-769616-g0003.jpg
case_images: PMC8818743_02_fcvm-08-769616-g0003.jpg
case_images: F3
case_images: Immediate transthoracic echocardiography with strain analysis documented diffuse left ventricular hypokinesia and increased thickness in the mid-ventricular septal wall (13 mm), and LVEF severely reduced to 26% (Figures 3A,C). Five days later, his temporary pacemaker was withdrawn with regular sinus rhythm, and at this time, the CMR test revealed a corresponding extensive myocardial edema and necrosis with predominant subepicardial/mid-ventricular septal distribution highly suggestive of a myocarditis pattern (Figures 3E,F). Ventricular septal myoedema was observed on T1 mapping, and the value of myocardial T1 was significantly increased (1,380 ms in the male patient, Figures 3I,J).
case_images: PMC8818743_02
case_images: (A) ECG for the woman patient when admitted to hospital: Sinus rhythm Right bundle branch block; (B) ECG of the man patient when admitted to hospital; V1-V3 lead ST-elevation and third-degree atrioventricular block; (C) ECG of the man patient when implanted with temporary pacing; (D) ECG of the man patient at discharge: Sinus rhythm, Right bundle branch block.
case_images: fcvm-08-769616-g0001.jpg
case_images: PMC8818743_02_fcvm-08-769616-g0001.jpg
case_images: F1
case_images: An emergency electrocardiogram revealed a third-degree atrioventricular block (AVB) (Figure 1B). Physical examination revealed a body temperature of 36.2 C, blood pressure of 101/60 mmHg, pulse of 77 bpm (pacemaker heart rate, Figure 1C), respiratory rate of 18 bpm, and blood oxygen saturation of 99% while the patient was breathing ambient air. After 9 days, the LVEF recovered to 59% with a normal sinus rhythm (Figure 1D) when he was discharged with oral beta-blockers (47.5 mg/day), perindopril (4 mg/day), and prednisone 20 mg/day.
case_images: The echocardiographic and cardiac magnetic resonance images recorded at admission and the findings of pathological specimens compatible with fulminant myocarditis. (A) LV ejection fraction was mildly reduced (EF value, 28%); (B) LV ejection fraction was mildly reduced (EF value = 30%); (C) Representative images of global longitudinal strains (GLS) presented as "bullseye" displays in case 1 (GLS = -12.1%); (D) Representative images of global longitudinal strains (GLS) presented as "bullseye" displays in case 2 (GLS = -9.8%); (E) Increased myocardial signal in the outer layer of the apical ventricular septum (edema) (arrow); (F) Late gadolinium enhancement imaging suggests myocardial enhancement in the outer layer of the apical ventricular septum (myocardial necrosis) (arrow); (G) Long-axis late gadolinium enhancement imaging suggests myocardial necrosis in the middle ventricular septum (red arrow), thinning, and enhancement of the lateral wall (yellow arrow); (H) Short axial late gadolinium enhancement imaging demonstrates myocardial necrosis in the middle ventricular septum (red arrow) with thinning of the lateral wall and formation of fibrosis (yellow arrow); (I) in T1 mapping, ventricular septal myocardial edema was observed, and the value of myocardial T1 was significantly increased, T1=1380 ms (normal value T1 = 1,180 +- 20 ms); (J) Myocardial edema in the lower interventricular septum was observed in T1 mapping, and the value of myocardial T1 was significantly increased, T1 = 1,364 ms (normal value T1 = 1,180 +- 20 ms); (K) Biopsy from myocardium showing myocardial fibers were slightly edematous and interstitial edema was accompanied by infiltration of inflammatory cells; (L) Biopsy from myocardium showing myocardial atrophy, hypertrophy of some cardiomyocytes, myocardial interstitial edema, local fibrosis, scattered focal necrosis of cardiomyocytes accompanied by infiltration of inflammatory cells.
case_images: fcvm-08-769616-g0003.jpg
case_images: PMC8818743_02_fcvm-08-769616-g0003.jpg
case_images: F3
case_images: Immediate transthoracic echocardiography with strain analysis documented diffuse left ventricular hypokinesia and increased thickness in the mid-ventricular septal wall (13 mm), and LVEF severely reduced to 26% (Figures 3A,C). Five days later, his temporary pacemaker was withdrawn with regular sinus rhythm, and at this time, the CMR test revealed a corresponding extensive myocardial edema and necrosis with predominant subepicardial/mid-ventricular septal distribution highly suggestive of a myocarditis pattern (Figures 3E,F). Ventricular septal myoedema was observed on T1 mapping, and the value of myocardial T1 was significantly increased (1,380 ms in the male patient, Figures 3I,J).