Cardiac Magnetic Resonance Imaging for Differentiating New-Onset Right-Sided Heart Failure
A 58-year-old man was admitted to our tertiary care hospital because of new-onset heart failure during the last 4 weeks and sustained ventricular tachycardia (Figure 1). Before admittance to our hospital, coronary artery disease was ruled out by coronary angiography at another hospital. At that time, left ventricular angiography showed slightly reduced left ventricular function and inferior hypokinesia. Chest x-ray at admission did not show any signs of congestion, but revealed a narrowed retrosternal space, giving reason to suspect right ventricular failure as the cause of fatigue and dyspnea (Figure 2). Cardiac magnetic resonance imaging showed poor right ventricular function and moderately reduced left ventricular function (Movies I and II in the online-only Data Supplement). Early gadolinium enhancement and T2-weighted imaging showed active inflammation (Figure 3). Late gadolinium enhancement showed enhancement of nearly the entire right ventricle (Figure 4) and involvement of the left ventricle. These findings on T2-weighted and early enhancement imaging gave reason to highly suspect active inflammation caused by myocarditis. Other causes of predominantly right ventricular cardiomyopathie, such as arrhythmogenic right ventricular cardiomyopathy, were unlikely. To confirm this hypothesis and to aid in decisions about immunosuppressive therapy, a myocardial biopsy was performed. The myocardial biopsy revealed giant-cell myocarditis (Figure 5) with extensive fibrosis. Corticosteroids and azathioprine were given. However, the patient remained unstable. A second magnetic resonance imaging 4 weeks later showed persistent poor right ventricular function; thus, the patient was placed on the list for highly urgent heart transplantation.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/123/13/1451/DC1.
- © 2011 American Heart Association, Inc.