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.