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Acute myocarditis after COVID-19 mRNA vaccination presenting with Ventricular Tachycardia
Session:
Sessão Speaker’s Corner - Casos clínicos desafiantes… em Cardiologia - 1
Speaker:
Carolina Pereira Mateus
Congress:
CPC 2022
Topic:
P. Other
Theme:
37. Miscellanea
Subtheme:
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Session Type:
Sessão de Casos Clínicos
FP Number:
---
Authors:
Carolina Pereira Mateus; Mariana Passos; Joana Lima Lopes; Inês Fialho; Marco Beringuilho; João Baltazar Ferreira; João Bicho Augusto; David Roque; Carlos Morais
Abstract
<p><span style="font-size:11pt"><span style="font-family:Arial"><span style="color:#000000">A 59-year-old male presented to the emergency department with acute onset of chest pain at rest, irradiating to his left arm and back. He also stated a 4-day history of diffuse abdominal pain, starting on the day he had the second dose of mRNA COVID-19 vaccination.</span></span></span></p> <p><span style="font-size:11pt"><span style="font-family:Arial"><span style="color:#000000">On physical examination the patient was hypertensive (150/70mmHg) and tachycardic (heart rate of 190bpm), with a peripheral oxygen saturation of 98% on room air. The admission 12-lead ECG (figure 1) revealed a monomorphic ventricular tachycardia (VT) with a left bundle branch block morphology. </span></span></span></p> <p><span style="font-size:11pt"><span style="font-family:Arial"><span style="color:#000000">Given the signs of impending instability we decided to proceed with synchronized electric cardioversion. After a single 200J biphasic shock, ECG was in sinus rhythm at 77bpm, ST-segment elevation in aVR and ST-segment depression in leads V2-V6, I, II and aVF.</span></span></span></p> <p><span style="font-size:11pt"><span style="font-family:Arial"><span style="color:#000000">Blood tests at admission showed no leukocytosis and C-Reactive Protein 0.16mg/dL. NT-proBNP was 172pg/mL and high sensitivity troponin T was 9ng/L (99th percentile <14ng/L) with a subsequent increase to 104ng/L.</span></span></span></p> <p><span style="font-size:11pt"><span style="font-family:Arial"><span style="color:#000000">The patient was started on intravenous amiodarone and admitted to the Intensive Coronary Care Unit.</span></span></span></p> <p><span style="font-size:11pt"><span style="font-family:Arial"><span style="color:#000000">The transthoracic echocardiogram showed a non-dilated and non-hypertrophied left ventricle with a left ventricular ejection fraction of 53%, and no regional wall motion abnormalities. The right ventricle was normal in size with preserved systolic function (TAPSE= 28mm, s´TDI= 17cm/s).</span></span></span></p> <p><span style="font-size:11pt"><span style="font-family:Arial"><span style="color:#000000">An invasive coronary angiography was performed, excluding significant coronary artery disease.</span></span></span></p> <p><span style="font-size:11pt"><span style="font-family:Arial"><span style="color:#000000">A cardiac MRI (figure 2) was performed 8 days after hospital admission, showing diffusely thickened left ventricular walls, with a subjective appearance of swollen myocardium, also confirmed by an hyperintense diffuse T2 signal (oedema) in the myocardium. There was a midwall patch of late gadolinium enhancement in the basal inferolateral wall. These findings were consistent with acute myocarditis.</span></span></span></p> <p><span style="font-size:11pt"><span style="font-family:Arial"><span style="color:#000000">Myocarditis after COVID-19 mRNA vaccination has been described as occurring most frequently in men aged less than 30 years, and starting 3 to 4 days after the second dose of the vaccine. Considering this case’s temporal association and cardiac MRI findings, we believe that the myocardial oedema and scarring were the cause of the VT in the setting of acute myocarditis, which was very likely triggered by the mRNA COVID-19 vaccination.</span></span></span></p> <p><span style="font-size:11pt"><span style="font-family:Arial"><span style="color:#000000">As a secondary prevention measure of sudden death, an implantable cardioverter-defibrillator was implanted in the same hospital admission. Until the date of submission of this case report (approximately 6 months), no recurrence of VT has occurred.</span></span></span></p> <p><span style="font-size:11pt"><span style="font-family:Arial"><span style="color:#000000">This case shows a rare form of presentation of myocarditis, and it reminds us of the need to pursue a thorough differential diagnosis.</span></span></span></p>
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