SYNCOPE AND CHB
Dr.Sepideh Jafari
Fellowship of heart failure and transplantation
Assistant professor at SBMU
Shahid Modarres Hospital
CASE
• A 34 year-old woman admitted to hospital with several episodes of transient LOC since the morning
• She reported history of chest pain and fatigue and GI discomfort since several days ago ,without any other symptoms
• She had negative past history without history of common cold
• Positive family history : SLE in her mother , Hashimoto thyroiditis in her sister
FIRST ECG
INITIAL LAB TESTS
• Positive troponin
• Normal RFT and biochemistry
• Limited bedside TTE :Normal LV size , EF=30-35% , Global HK
• Normal RV size mild dysfunction
• Plan : Patient was referred to “ Shahid Modarres Hospital “ for TPM insertion and coronary angiography ( on inotrope :dopamine)
POST CPR (ASYSTOLE)
IS THIS ANOMALY THE MAIN CAUSE OF
SYMPOTOMS?
COMPLETE LAB TESTS
• Trop I= 4.9 WBC=8000
• Urea= 35 neutrophil=80%
• Cr=1.04 TSH=2.1
• D dimer =5165 CRP=1+
• CPK=281 Pro BNP=3100
• CKMB=77 U/A :normal
• Hb=10.2
WHAT SHOULD BE THE NEXT STEP ?
• Methylprednisolone (3 days ) +cellcept
• EMB
• PPM insertion (two chambers) due to recurrent LOC and one episode of ASYSTOLE
RHC AND EMB
Parameter Unit
Cardiac Out put 3.6 lit/min
Cardiac index 2.4 lit/min/m2
PAP 26/13 mmHg (17.3)
RAP 8 mmHg
PCWP 16 mmHg
PVR 0.3 woods unit
SVR 20.5 woods unit
MVO2 62 %
THE NEXT DAY….
FOLLOW UP ECHO (ON IMMUNOSUPPRESSION)
• Normal LV size EF=40-45 % , Global HK , Hyper trabeculation(apex , posterior and inferior wall)
• No DD
• Normal RV size , mild dysfunction
• No MS , mild to mod MR
• No AS , No AI
• Mild TR , SPAP=25 , Normal IVC
4 months later
PPM analysis : V pacing < 1%
ALL RHEUMATOLOGIC STUDIES ARE NEGATIVE
• Anti phospholipid Ab
• Anticardiolipin Ab
• ANA ,Anti ds -DNA
• ANCA
• C3 , C4 , CH50
• IL-6
• ACE level
WHAT IS THE ROLE OF EMB ?
• myocarditis
• cardiomyopathies
• drug-related cardiotoxicity
• Amyloidosis and other infiltrative and storage disorders
• cardiac tumors
HFA/HFSA/JHFS Position Statement on Endomyocardial Biopsy , Seferovic et al. JCF 2021
• A study of 755 patients with suspected myocarditis and
nonischaemic cardiomyopathy (including infiltrative and storage
disorders) indicated that biventricular EMB can increase
diagnostic accuracy compared with selective LV- or RV EMB
• Less than 1 % major complication in experienced centers
HFA/HFSA/JHFS Position Statement on Endomyocardial Biopsy , Seferovic et al. JCF 2021
• CMR-directed EMB can improve procedural accuracy in diseases
with focal pattern (e.g. sarcoidosis)
• concordance between CMR and EMB findings is only partial and
that these procedures have a complementary role in diagnostic
assessment
HFA/HFSA/JHFS Position Statement on Endomyocardial Biopsy , Seferovic et al. JCF 2021
Current state of knowledge on aetiology,diagnosis,management of myocarditis Caforio et al European heart journal 2013
1998 -2007, nine pediatric patients (aged from 1.5 to 16
years)
• After the acute phase of idiopathic lymphocytic myocarditis, which undergoes spontaneous resolution in up to 40% of the cases, at least some patients with persisting myocarditis and chronic heart failure are likely to benefit from immunosuppression.
• At present, immunosuppression is recommended essentially for the treatment of eosinophilic, granulomatous, giant-cell myocarditis and lymphocytic myocarditis associated with connective tissue diseases or with transplanted heart rejection.