case_images: PMC10012167_01
case_images: ECG. Diffuse low voltage in the acute phase with gradual normalization over a period of about 20 days was observed.
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case_images: The ECG showed sinus tachycardia with a rate of 122 beats per minute (bpm), diffuse low voltages, and the absence of significant repolarization abnormalities (Fig. 1).
case_images: TTE. Several areas of increased myocardial echogenicity (arrows) involving the ventricular septum, the anterior, lateral, inferior walls and the RV free wall were detected.
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case_images: Troponin (hs-Tn) with a value of 23000 ng/L, elevated brain natriuretic peptide (BNP) with a value of 6890 pg/ml, elevated creatinine with a value of 1.8 mg/dl and transaminases and total bilirubin; reverse transcription-polymerase chain reaction (RT-PCR) nasopharyngeal swab for COVID-19 was negative. COVID-19 IgM antibody test was performed resulting in high IgM levels. The TTE showed normal left ventricular (LV) cavitary dimensions, as expressed by an indexed end-diastolic volume (EDVi) of 41 ml/m2, diffuse LV parietal thickening with thicknesses of 15-16 mm, not present in a TTE performed a few weeks earlier, with several areas of increased myocardial echogenicity (Fig. 2), severely reduced LV global systolic function with an ejection fraction (EF) quantified by Simpson biplane method of 26%, a dP/dT ratio of 672 mmHg/sec, indexed stroke volume (SVi) calculated by velocity-time integral (VTI) method of 11 ml/m2 with a cardiac index (CI) of 1.3 l/min/m2, elements defining the picture of low output.
case_images: This graph depicts the improvement in left ventricular systolic performance indices over time. Of note, concomitant with this improvement was no substantial change in afterload, as expressed by LV and RV size, afterload in relation to Norepinephrine rate infusion, and indices of inflammation.
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case_images: Figure 3 depicts the trend of the indices of LV and RV systolic performance as well as the indices of preload, afterload and inflammation over time.
case_images: CMR. In the TIR/t2w sequences, there was an increase in signal intensity compatible with edema, spread to almost all LV myocardial segments, with a higher ratio seen with subendocardial localization to the basal and middle segments of the interventricular septum, both on the right and left sides of it, the inferior basal wall, and the basal and middle segments of the lateral and inferolateral walls, in the latter case with almost total transmurality. In addition, edema was seen involving the basal segments of the RV free wall and the pericardium at the lateral level (A and B, white arrows). To the areas of edema, corresponded enhancement in the EGE (not shown) and LGE sequences (C and D, white arrows). At the level of the lateral wall, in the area characterized by edema and enhancement, there was a stria with the same signal intensity as in healthy myocardium suggesting a spared area (yellow arrows).
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case_images: Furthermore, edema and EGE/LGE, involving basal segments of the free wall of the RV and the pericardium at the lateral level, were detected. (Fig. 4).