Korean Circ J.  2013 Aug;43(8):565-568. 10.4070/kcj.2013.43.8.565.

A Case of Reversible Very Low Voltage Electrocardiogram in Fulminant Myocarditis

• Lee JM
• Seo SM
• Seo MJ
• Min HK
• Cho MJ
• Kim YS
• Kim YS
• Baek SH

• KMID: 2224848
• DOI: http://doi.org/10.4070/kcj.2013.43.8.565

Abstract

Clinical features of acute myocarditis range from a subclinical state to a fulminant state. Fulminant myocarditis with ventricular arrhythmia or atrioventricular block is associated with a high mortality rate. In cases in which aggressive medical therapy for fulminant myocarditis is not likely to be successful, intensive and emergency mechanical circulatory support, such as extracorporeal membrane oxygenation (ECMO) or intra-aortic balloon pump, should be considered. We report life salvage of acute fulminant myocarditis in a 53-year-old woman presented with malignant arrhythmia and cardiogenic shock supported by ECMO.

Keyword

Myocarditis; Arrhythmia; Extracorporeal membrane oxygenation

MeSH Terms

Arrhythmias, Cardiac
Atrioventricular Block
Electrocardiography
Emergencies
Extracorporeal Membrane Oxygenation
Female
Humans
Middle Aged
Myocarditis
Shock, Cardiogenic

Figure

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  Fig. 1 The electrocardiogram findings. A: incomplete right bundle branch block with ST-segment depression in diffuse precordial leads. B: wide QRS tachycardia with left bundle branch block (LBBB) pattern. C: atrial fibrillation with LBBB pattern of QRS. D: little or no electrical activities. E: junctional rhythm with low voltage and atrioventricular dissociation. F: sinus rhythm with Q-wave in V 1-3, negative T wave in II, III, aVF, V 5, V 6.

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  Fig. 2 Coronary angiography shows a near-normal coronary artery. A: left coronary artery. B: right coronary artery.

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  Fig. 3 M-mode of echocardiography findings. A: akinesia of anterior wall motion. B and C: worsening of wall motion abnormality. D: slight improvement of wall motion.

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  Fig. 4 Cardiac MRI shows delayed enhancement on the transmural thickness of the mid to apical antero-septal wall. A: 2 chamber view. B: 4 chamber view.

Reference

1. Feldman AM, McNamara D. Myocarditis. N Engl J Med. 2000; 343:1388–1398.

2. Morgera T, Di Lenarda A, Dreas L, et al. Electrocardiography of myocarditis revisited: clinical and prognostic significance of electrocardiographic changes. Am Heart J. 1992; 124:455–467.

3. Bruch C, Schmermund A, Dagres N, et al. Changes in QRS voltage in cardiac tamponade and pericardial effusion: reversibility after pericardiocentesis and after anti-inflammatory drug treatment. J Am Coll Cardiol. 2001; 38:219–226.

4. Hare JM, Baughman KL. Fulminant and acute lymphocytic myocarditis: the prognostic value of clinicopathological classification. Eur Heart J. 2001; 22:269–270.

5. McCarthy RE 3rd, Boehmer JP, Hruban RH, et al. Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis. N Engl J Med. 2000; 342:690–695.

6. Aoyama N, Izumi T, Hiramori K, et al. National survey of fulminant myocarditis in Japan: therapeutic guidelines and long-term prognosis of using percutaneous cardiopulmonary support for fulminant myocarditis (special report from a scientific committee). Circ J. 2002; 66:133–144.

7. Marasco SF, Lukas G, McDonald M, McMillan J, Ihle B. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart Lung Circ. 2008; 17:Suppl 4. S41–S47.

8. Slaughter MS, Rogers JG, Milano CA, et al. Advanced heart failure treated with continuous-flow left ventricular assist device. N Engl J Med. 2009; 361:2241–2251.