Resuscitated ventricular fibrillation secondary to myocarditis (possible inverted Takotsubo cardiomyopathy)

Introduction: Sudden cardiac death (SCD) may mani-fest in the general population, with no prior history of cardiovascular disease and remains a controversial to-pic in cardiology. The multiple causes of SCD (from co-ronary artery disease, arrhythmias associated with cardiomyopathy or channelopathies) make both the prevention and treatment of SCD to remain a challenge.
Case presentation: We present the case of a 57 years old male, active smoker, with no history of cardiovascular disease, who suffered a cardiac arrest when travelling by bus. Basic life support (BLS) was given by the bus driven, followed by advanced life support measures (ALS) by ambulance crew. Ventricular fibrillation was shocked with return of spontaneous circulation (ROSC) after almost 10 minutes from arrest. ECG after defibrillation shows sinus rhythm with right bundle branch block and ST-T and T changes in the anterior leads and avR. Cardiac necrosis markers were elevated and inflammatory markers were high with normal electrolytes. Computed tomography (CT) of the thorax excluded an aortic dissection or a pulmonary embolism. CT of the brain did not show any signs of acute stroke or hemorrhage. The patient is hemodynamically stable with no need for inotropes or pressors but it is maintain sedated for another twelve hours. Transthoracic echocardiography shows moderately impaired left systolic function (LVEF 40%), with hypokinesis of the basal anterior, lateral walls and septum , no significant valve disease. Coronary angiography shows normal co-ronaries and left ventricle angiogram shows hypokinesis of the basal segments with an overall EF estimated at 50%. Favourable evolution, he is taken off the ventilator second day after admission. A collateral history obtained from his family suggests a respiratory viral episode two weeks before the episode. The patient received standard treatment for heart failure (betablocker, ACE-inhibitor, diuretic). He is stable hemodynamically and with no further ventricular arrhythmias. An echo re-evaluation at one month shows improved EF and no wall motion abnormalities.
Conclusions: Considering the history, clinical and paraclinical tests we concluded that the SCD episode was most probably secondary to a myocarditis episode. The imaging examination (both echo and LV angiogram) may suggest Inverted Takotsubo Cardiomyopathy, but we could not identify any clear major stress episode as a trigger. The favourable evolution emphasis the importance of early resuscitation measures and also the multidisciplinary approach of those patients in order to improve the prognosis.

ISSN – online: 2734 – 6382
ISSN-L 1220-658X
ISSN – print: 1220-658X
The Romanian Journal of Cardiology is indexed by:
ESC search engine
CODE: 379
CME Credits: 10 (Romanian College of Physicians)