Echocardiographic Description of Recurrent Idiopathic Giant-Cell Myocarditis in Cardiac Allograft
A 23-year-old woman with a cardiac allograft transplanted for giant-cell myocarditis 4 years earlier presented with exertional dyspnea. Her chest x-ray showed a normal cardiothoracic ratio and mild pulmonary venous congestion. An ECG demonstrated sinus rhythm with partial right bundle branch block. Conventional echocardiogram was essentially normal with only the interventricular septum being severely hypokinetic. The left ventricle (LV) was of normal size with low-normal systolic function (Figure 1). The right ventricle was of normal size and function. There was mild tricuspid regurgitation with a right ventricular systolic pressure of 31 mm Hg. There was no significant pericardial effusion. Doppler mitral inflow and pulmonary venous flow indices showed abnormal LV relaxation and elevated LV end- diastolic filling pressure. Color M-mode Doppler tissue echocardiography (DTE) showed an abnormally positive myocardial velocity gradient (MVG) across the LV posterior wall during isovolumic relaxation and a reduction during rapid ventricular filling indicating impaired myocardial relaxation (Figure 2). There was a reduction of early diastolic tricuspid annulus velocities and a virtual lack of medial annulus velocities with normal lateral mitral annulus velocities by pulsed-wave DTE (Figure 3). Described abnormalities in MVG and annular velocities were consistent with the features of an allograft rejection. Right ventricular endocardial biopsy showed giant-cell myocarditis in the transplanted heart (Figure 4). The patient was given high-dose immunosuppressive therapy and made a full recovery.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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