31. Fulminant Myocarditis with Cardiogenic Shock Case Discussion
Worldwide cardiovascular disease affects the lives of hundreds of millions dedicated cardio nerds everywhere are working hard to fight this global epidemic. These are their stories. Welcome back Carter. We're just so incredibly excited to jump into today's case discussion but before we do we just wanted to take a moment and reflect on what a journey cardiologists has been for all of us as many of you know we launched the show in December and just were so overwhelmed with the amount of tremendous feedback and support from you. This marks our first episode after one hundred thousand downloads of the show and this is a benchmark that we are celebrating together with all of you since launch. We've had eighty two voices on the show in our youtube channel. Our website which all the podcast episodes youtube videos tweets oriels and so much more has been accessed in one hundred twenty countries. We just cannot thank you all enough. Simplest picking the existence of the Cardi is not possible without the incredible support from our mentors colleagues and listeners. As an education platform it really is a collective owned by the community at large and for that the four of us Dan Corinne Heather and I are eternally grateful for your support. We are especially indebted to resume. Nash Clinical Problem solvers for giving us the initial push to dive into this adventure and the Cleveland Clinic Foundation's Alumni Association for their very generous educational grant to support our ongoing growth when resume. I encouraged us to do this. We couldn't imagine having the time or the support. Eventually in a skeptically we decided to produce a five series to see if it was even feasible for our busy lives as fellows and parents but here we are thirty episodes later and still going strong. Well I guess I should say one if you include this one. Speaking of which in the current episode we go through our Comprehensive Cardi nerds approach to Microsoft Office with just five foundational principles. We end with a very special message from to surprise guests and this sets the stage for next episode. Just remember that this podcast is not meant to be used for medical advice. The views expressed here do not reflect the opinions or policies of our employers. The case you're about to hear is one hundred percent hip compliant. Some details were changed to protect privacy. But out of respect for the patient the rest is told exactly as it occurred. Cardio anyone for a coffee break all. Am In oh man. I have just the place to go right. Guys take it away. I'll go get some coffee guys. I've got to tell you about a crazy case that I had a while. Back as you'll see it's a case that has been completely perspective altering and career bending for me and I think about this patient all the time him and actually entire do tell especially now that we're in a private area with no risk of Hesse violation. Mike wink okay. At the time the patient was a thirty five year old man with no past medical history. He was feeling well Rockin at his job and was building a beautiful family with his wife who was midway through a pregnancy four days prior to admission he developed headaches diffuse body with fatigue now he also had large volume diarrhea nausea and repeated bats of vomiting on the Dan presentation he developed a fever to one or two point six Fahrenheit warmer Wow the sounds like a pretty acute and diffuse process fever and systemic illness. In previously healthy young man already has me thinking about infectious etiologies rather than auto immune or auto inflammatory. Though at the back of my mind there are non infectious causes for fever fatigue. Diarrhea like inflammatory bowel disease. Thyroid tax coasts. But right now definitely infection infection infection yet. He was feeling really crappy. His wife insisted that seek medical attention in the hospital and she helped him get into the car and they started driving to the local. Ed En route the patient lost consciousness and slumped over for about a minute but he woke up spontaneously his vital signs and the locally. D were notable for sinus tech occurred. It's one forties blood pressure of one hundred sixty five millimeters of mercury and. His temperature was thirty nine point three Celsius which has one or two point seven Fahrenheit e. G showed sinus ticket. Cardia a right bundle branch block with a right axis. Deviation Laverick was notable furniture opponent I level of eighty seven point seven nanograms per milliliter he was treated with four liters of IV fluids empirical antibiotics and transferred to our hospital. Oh Nice looks like I got back just at the right time. There's a lot to unpack here. But I'm totally building off. Heather's initial impressions the episode of Syncope and and Cardio are screaming alarm bells here heather. Let's breakdown syncope first and then we can build it from there. Yes let's do it. I usually break it down into four big buckets. The first bucket is or the static syncope which can be from volume loss automatic dysfunction and certain meds like Tam Salosa N-. He may be volume down given his acute illness especially with the diarrhea. Second Bucket is flexing copy which is a transient autonomic. Response WITH LOSS OF HEART. Rate and pressure and can be from. Karadic bull hypersensitivity or a typical vase available response which can occur spontaneously or in response to situations like seeing blood third. Big Bucket is cardiac arrhythmic which includes things like Brady Arrhythmias tacky arrhythmias which are often described as sudden loss of consciousness without a warning and without a program and the fourth bucket last but not least is cardiac mechanical causes which are signal events from specific cardiac structural abnormalities the result in obstruction of cardiac output. Valvular like a notice. Myocardial like hypertrophic cardiomyopathy severe heart failure vascular. Pulmonary embolism pulmonary. Hypertension riddick dissection pericardial like a fusion or constriction perfect. Now let's tie that into the rest of his presentation. The Tech Cardia is certainly ominous and can be a response to systemic profusion. And or hyper address extinct. Probably both now when I was in the bay view. See Acu Daca. Steve Shoe Hopkins Heart failure tending who was featured in episode fifteen teaching. All about Elvis once came up to me and said hey amish what's the scariest rhythm in the EU? And of course I said V. FIB he said. Now you know V. Fair. We have a plan for that. The scariest rhythm for me is sinus ticket. Cardio and I'm certainly worried about this patient. With a Science Cardio when tackling case in general. It's helpful to latch onto the most specific finding in. Here that's a proponent Dan. What's your approach atropine? Nemea I never ask unlike. Ck proponent specific my cardio biomarker so we cards just love it but not every opponent leak is an acute coronary syndrome. So let's break it down remembering coronary. Profusion pressure is the pressure gradient that's required to push the goodies such as oxygen and nutrients across the capillary bed so the myocytes can take part of the feast. Now remember much of the blood flow down. The coronary arteries occurs during dastardly. When they ordered thou costs are closed and blood in the order flows down those corners and the corner. Capillaries are not being squeezed shut by the systolic pressures that the left ventricle generates the gradient across the left ventricular capillary. Bed is going to be the difference. Between the diastolic blood pressure of the coronary arteries and the left ventricular end diastolic blood pressure. Which is the pressure in the left ventricle during that. Same time to highlight this concept. We can think about the following example. Say a patient has a proximal left anterior descending artery acute inclusion that leads to an anterior s the elevation Emma I his entire anterior wall acutely kinetic resulting in hypertension and heart failure. We know that the territory of the L. A. D. is going to be ischemic because of the stemming but the my cards supplied by the right coronary artery. And the circumflex. Arteries are going to become a schemic. The dice dot blood pressure will be low. Because of the shot and the left ventricular diastolic blood. Pressure will be elevated because of the heart failure. Since the coronary profusion pressure which is diastolic blood pressure minus left ventricular end diastolic. Blood pressure will be low. All of the myocardium will become ischemic. Leading to worsening hypertension and increased left ventricular diastolic pressure and this cycle will continue until there is some sort of intervention. Dan. That is a great way of thinking about coronary profusion. Thank you for explaining that. I know when I'm admitting patients from the emergency room. To the hospital with positive proponent. I think things broadly. In this way proponent leaks into the bloodstream. When there's mile site deaths from one supply demand mismatch or to direct miles site injury from something else to get a little bit more into the Nitty Gritty? If we're talking about supply demand mismatch. You can have poor supply AKA poor perfusion of the coronaries which can be from things like a type one am I with acute plaque rupture what we traditionally think of as acute coronary syndrome but it can also be from things like spontaneous coronary artery dissection a scattered which really deserves its own episode entirely. So we'll talk about that in the future and along with Vitamin Mitch match. You can also have increased demand with or without baseline obstructive coronary arteries meaning that the heart is working harder and soon needs oxygen out of that blood. Increased demand can be from increases in after load increases in heart rate or contract TILLEKE OR INCREASES IN END DIASTOLIC PRESSURE AKA increase wall stress. So things that increase after load can be hypertension. Think if we double blood pressure than the left. Ventricle has to double its Solid pressure working more over time. And things like Eric's diagnosis can increase after load as well and then talking about cardio which can be sign a second cardia or atrial fibrillation with our VR. That can also cause increased demand. And you can have things that increase your left and trickier diastolic pressure. Like valvular such as Stenosis or cardiomyopathy which increase your wall stress and increase your demand so that supply demand and then you can also have direct miles say injury from things like infiltration of amyloid or other infiltrative. Cardi Matthys myocarditis which can be related to a virus or site kind storm where a lot of other ideologies or trauma. Heather that was a great breakdown of causes of trump anemia. But let me just throwing a wrench and mentioned as the sideline the concert of minocha my cardio infarction with non obstructive corny arteries now. I'm not sure how I feel about this whole entity but generally it's the clinical diagnosis of an m. i. based by Margaret Trend. Maybe even occurred Marai but with a coronary angiogram that at least on face value does not show obstruction. So whenever I think about determine OKA- is remember back to a very passionate discussion. I had with my Coachella David Niebuhr in our fellow office. One of my favorite places in the hospital in his major qualm with a term was that it is so nebulous with the changing definition. A Heterogenous Hodgepodge of underlying pathology moreover. It's really just a descriptive term again. Am I with negative coronary Angiogram? It's not a diagnosis so underlying David's point. That minogue are no MINOCHA. You should just describe what's happening but really focus on using your diagnostic arsenal to make a true diagnosis. I'll direct our listeners are wonderful. Aj Scientific Statement on the matter in circulation twenty nine thousand nine by Thomas Holland at all overall. Taking this back to our patient acute coronary syndrome is less likely in a young guy without traditional risk. Factors Dan Ahmed. And that's great explanation of trope. Anemia public service announcement for everyone to opponent is not always an M. I think through this break down and get to the heart of the problem Korean. I couldn't agree with you more on that. Getting back to our taste. The key elements of this presentation are an inflammatory state. Syncope Michael Injury guys this three way. Then diagram is a prototypical. Trifecta for my credit is now. Let's not anger on this just yet. And let's make sure that we include the other life threatening things on their differential diagnosis like sepsis pulmonary. Embolism and acute coronary syndrome. Because after all missing any of these would be hard to forgive. Yes I love that differential given that this patient as systemic symptoms that really point to an inflammatory state. I agree with you on that. This would definitely fit in nicely with a myocarditis Korean. Those were thoughts as well when he arrived our cardiac ICU. His blood pressure was ninety. Five over sixty of mercury heart rate. One Oh six beats per minute respiratory rate twenty three breath permits adding ninety five percent initially on room air. He looked super nervous and incredibly. Soak the sheets. Dia foretich will not appreciate any cervical infant not being his. Jvp was measured around ten centimeters. He was tackled. Kartik without any appreciated rub murmurs. He had mild by Basil crackles. He had trace lower extremity Dima in his legs and his honestly has lower extremities. Were quite cool to the touch. No Rashes were noted on a full skin survey. His white blood count was nine hemoglobin. Fourteen platelets one eighty four CRATON. One point one two opponent I was not checked at our institution and was thirty. One nanograms per milliliter and trended downwards to twenty seven C K peak was six twenty five units per liter micro studies were sent and included a rapid HIV test. Syphilis Coxsackie Adenovirus lime disease that all alternately returned negative bacteria cultures were negative as well. Tsa was normal. A chest X ray showed pulmonary vastly congestion and a small right pleural fusion. A central line was placed in the right internal jugular vein given the opponents suspicion for cardiac dysfunction. We snag a Central Vinasat which was forty two percent. My my Dan. This sounds like a pretty impressive case. So far your patient had a lot of GI upset with nausea vomiting and those symptoms can certainly be related to an underlying inflammatory illness which sounds viral with his overall picture. But let's remember with his Kartik injury his physical exam and low CD peace at really worried about RV failure and low cardiac output which often causes these big abdominal complaints thinking back as global perfusion. I know you mentioned. He was cool on exam. But can you also tell us about his mental status and urinary output absolutely? I'm an excellent point. Our patients mental status is actually fairly reasonable. He was alert and really asking us to help him out with his profound nausea on exam. He was definitely cold and clammy. We also noticed that he had not put out an ounce of urine since arrival are Ashville and that was also the case while he was in the emergency room before he came over. Well Sue. Now we're really dealing with a young man who presents with an acute. Inflammatory Syndrome has markedly elevated proponent and is exhibiting signs and symptoms of. Hypo perfusion and congestion. We need to get a jump start on both management and simultaneously an rather quickly making the diagnosis to address the underlying culprit. I'd love to learn y'all's approach to cardiac shock in the C. See you at some point but let's get started on diagnosing the underlying problem. I I totally agree that my data sounds like the prime suspect here. You got it friends. Let's return to fundamentals of human dynamics and are pushed to Cartagena Shock. On one of our upcoming Cardi nerds coffee powwows but for now let's dive into the fiery world of microbes Hashtag Cardi nerds. Comprehensive Approach to my cart is is founded on just five basic principles number one build a clinical suspicion for Microsoft office including importantly excluding other possibilities number to decide. If an end of myocardial biopsy is necessary number three manage the acute cardiac injury number four manage the chronic szekely and number five. Treat the microbusiness. Nice breakdown. I'm it really helps. Make sure we don't miss anything in approaching a case of possible myocarditis but it all starts with step number one. You can't help a patient with Myocarditis. If you don't think about myocarditis particularly for Myocarditis a high index of suspicion is key because of the variability in presentation which spans from the very dull to the region firestorm on the dull a patient can be relatively symptomatic but on the opposite extreme. These patients can be extremely sick coming in with acute heart failure including Cardio Genyk shop electrical instability with both Brady Arrhythmias including heart block and tackle with Mia's sudden-death and associated pericarditis with Tampa nod these latter presentations especially with associated. Shock are by definition. Fulminate myocarditis right at the outset. This patient syncope is concerning for a full minute presentation. Most patients will have a viral proteome since viral. Marker Davis is the most common cause as well as constitutional symptoms reflecting the underlying immune. Activation specific symptoms are variable and nonspecific such as fevers rash body aches fatigue respiratory or gi. Complaints this also fits with your patient. Dan Corinne one hundred percent are patient for sure was looking more and more like a minute presentation especially with his initial central Venus O. Two sat cool extremities zero urinary output. His lactate was initially two point. Four million miles per liter but increase the four point six over just several hours because we Yeah it was bad because we were concerned about mix or Cardi genyk shock replaced. Pa CATHETER WHICH SHOWED IN STANDARD UNITS A. Right atrial pressure fifteen. Rv pressure thirty three over. Twelve P A thirty two over twenty three with a mean of twenty six a wedge pressure of twenty three cardiac index by Thermo Dilution Method. Was Two point two systemic vascular resistance index or SVR. I was twenty four hundred and pulmonary vascular resistance or PBR was hero. Point six are. Pa Sat returned. That forty nine point six percent okay. I'll take a crack at interpreting. These numbers his right hard left. Heart and pulmonary pressures are all elevated an proportionately elevated with to me makes me think that it's more consistent with heart failure unless so sepsis or a right sided primary issues like pulmonary embolism. His cardiac index is low again consistent with heart failure with a low flow state his pulmonary vascular resistance. Pdr IS NORMAL. Which is reassuring that he doesn't have underlying pulmonary hypertension. His systemic vascular resistance index is elevated probably compensatory in the setting of poor cardiac output and finally the pulmonary. Arterial sat a forty nine point. Six percent is low consistent with a low flow state with high peripheral oxygen extraction. All of this in a patient who is showing signs and symptoms of hyper. Perfusion is Cardi shop for me given the discussion. We've had so far. His presentation overall does sound like myocarditis. Let's definitely rule out other life threatening causes bar infectious. Workup IS NEGATIVE AND THYROID. Levels are normal Bravo Heather. That was just a marvelous interpretation of his awesome. And you know it really confirms that are dear. Patient is encouraging shock. Now we need to figure out why and treat it of course a big part of step one in building. Our suspicion for microdyne office is making sure. It's not one of the other more common causes of cardiac injury with Chuck. We should still think about pulmonary. Embolism structural heart disease like h which was sub clinical until he got infected stress cardiomyopathy and accredits with acute valvular pathology pericardial fusion. With temple and coronary causes these all fall under the supply. Demand imbalance bucket of trope anemia. While he had few risk factors for atherosclerosis. Remember not all coronary. Ischemia is from Athens Colorado Plaque rupture you can have dramatic coronary. Embolism coordinate. A section cornered SANSOM's vascular congenital anomalies. And so much more all in all. I'm about to off my seat. Dan for you to tell us about the echo and coronary imaging in this gentleman beauty. Yes this takes me back to how we organized cardiac pathology back in episode seven when we discuss cardiac amyloid. Let's think about the five failures. Coronary ventricular valvular electrical and pericardial failures. All of these are critical to think about when knocking off the differential diagnosis. In our case we ended up seeing Dynamic E C. G changes and given everything else going on we decided to pursue left heart catheterization with coronary angiography for all the reasons than almond outline. And guess what it showed normal coronary arteries. The initial echo showed a normal size and wall thickness. The junction fraction was forty percent. There was severe hypoc nieces of the Basil Amid Septum. In in for lateral walls the left ventricular walls were hypo kinetic. There was also a small parker diffusion without any evidence of Tempe. I'd repeated echo several hours later by myself. In the unit in the setting of worsening blood pressure on clinical decline showed a left lane rejection fraction of twenty to twenty five percent severe global. Hypoc ANISA's with the left ventricle average global longitudinal strain of negative by percent now seem reduction insists. Alec Motion Normal. Lv size in wall. Thickness really speaks to this acute process. That's unfolding before our eyes. Yeah I totally agree. We actually toyed with getting a cardiac Marai but it became quickly apparent that we would not gonna be able to move the patient and get an. Mri scanner for a period of time without jeopardizing his safety so he quickly abandoned that idea but in general for our listeners. Cardiac MRI is incredibly useful for the diagnosis of Microdyne Because you could see a Dima inflammation. This is such an important topic that we definitely have plans to discuss his future pulse. Check episode down the road. This is a pretty impressive presentation and I can see that in back. End from al-Qaeda's is really quite high. I've been looking for an approach to frame Actually Cardio nerds. This is the perfect time to discuss that. What's an approach that you find useful love it? There are so many ways to classify myocarditis. It really depends if you're an academic diagnostician visual pathologists or pragmatic clinician. Diagnostician will create a beautiful Schema outlining the ideology. So let's start there. Broadly speaking causes of microlight is can be split into infectious and non infectious for the infectious causes. Think about all. Those critters are micro tells like some odd love talking about number one by far and away the most common viruses. These are definitely the most common in developed countries and include central viruses coxsackie. Adenovirus ages should be six PARVO virus be nineteen and so much more. The SARS virus causing Kobe nineteen is an immersion. 'cause let's not. Forget the other micro nerd buckets so number. Two bacterial causes like I recall diseases parakeets line Michael bacterial and even the typical genyk Victoria number. Three protozoa like Chicago's disease from Japan. So Makuuchi number four fungal diseases like Aspergillus in cardio and finally number five parasites like kind of caucus now. That's a lot of our micro nurse but all in all the viral ideologies are the most common that turned out the diagnostician Schema with the non infectious causes which broadly include immunologic and toxic immunologic causes are broad and can be split into one myocardial involvement of systemic autoimmune process like lupus. Scleroderma shots Kawasaki Disease and Sarcoidosis to Philip Syndromes. Which can be primary like ats or GPA or secondary from hypersensitivity reaction to some trigger like a medication cancer or infection. And you'll myocardial fibrosis is a primary idiopathic use. Nfl ICK process that belongs here to acute use. Nfl Necrotizing Myocarditis the feared Yosano. Philip myocarditis that often presents with fallen in heart failure or sudden death and is most frequently caused by drug hypersensitivity but can also result from H. E. S. E. GPA and other NFL syndromes. Three there are three special. Immunologic causes that warrant attention. Giant cell myocarditis is a special beast on its own. As a cardiac specific auto antigen response characterized by giant cells and usually occurs with a full minen course immune checkpoint inhibitors have been a breakthrough in oncology and have had a tremendous impact on cancer therapy by taking off the usual breaks on the immune system which can then freely target cells but unfortunately the immune system can also target normal cells including ascites baking myocarditis. One of the many IRA or immune related adverse events. Finally heart transplant rejection caused by Allo. Antigen response is an important form of myocarditis and transplant recipients. Toxic myocarditis is simply a direct toxic effect from a host of substances including medications like Chemo Therapeutic agents illicit drugs heavy metals and dodging US molecules like late chain amyloid and other substances so to summarize the diagnostician approach to microbusinesses infectious immunologic and toxic. Don't worry this will all make for a beautiful diagnostic Schema that we will make available to you on our website. Let's think about this from a visual pathologist perspective generally there's a lot of overlap in the path findings from different types of microbes but the broad categories under the microscope include lymphocytic giant cell sarcoidosis and other granny luminous forms. Espn AFFLECK and you traffic. The logic pathologic associations aren't one to one or strict but they soldier can be helpful with thinking through the ideology Prognosis Entry. Response for instance. Lymphocytic microdots is the most common subtype is usually associated with viruses or disorders less likely to respond to immunosuppression but is generally favorable long term prognosis. However on the other hand giant. Cell Microdyne is uncommon frequently fatal but more likely to respond to suppression. So the information we get from our pathologists can be really helpful beyond basic histology. Pathologists are well equipped with several tools to assist in the diagnosis immuno. History Chemistry helps better characterize the inflammatory infiltrates and increases the diagnostic yield of biopsies and molecular. Typing helps aid in the definition of specific infectious agents. The work pathologists do has been incredibly helpful to better understand these diseases. That's awesome it. The diagnostic Schema and the pathologists slides are super duper helpful. But let's turn to the pragmatic clinician. Who's got the patient in front of them before they have any path or definitive ideology from the clinicians perspective. At this point in the case it's helpful to make one simple but only critical distinction. Is this fulminate myocarditis not full minute- micronized notice? That is the question. The answer makes a difference of how to proceed. And what you do next the twenty twenty. Aj Scientific statement defined full minute- myocarditis as I quote as sudden and severe inflammation of my car resulting in myocytes necrosis Edina Encarta Jenex shop in our patient by definition has full minute- microdyne as importantly Is a clinical syndrome. But it can arise from the many ideologies of the diagnostic Schema. And it can have any of the different histology pathologist microscope. Okay got it step number? One isn't so bad simply put we have successfully built our clinical suspicion for myocarditis based on the clinical presentation cardiac imaging and ruling out other diagnoses of which acute coronary syndrome is the most common. Considering the causes and approach myocarditis there are three straightforward classification schemes. I The ideology second the pathology and third the clinical presentation. So how do we put all this together to take care of the patient? Heather that is the crux with question. The ideology pathology and clinical presentation are all interlinked and especially for Microsoft Office in Guiding Diagnosis and treatment for the patients. This brings us to step number two at this point in the case dance team has conquered step number one for his patient in building a bulletproof suspicion for Microsoft Office. Now instead number two we have to decide as a team rather not to take our patient for an end of my cardio. Biopsy is tissue. The issue not always. Here's a mine twister. You only get an endo myocardial biopsy if the results will impact your management the role of the cardio biopsy in suspected mccray has always been an issue of debate on the one hand. It's the gold standard. As we've said we can learn so much from the pathology but on the other hand it is invasive and does carry some risk although this is minimal in the right hands more importantly myocarditis can be patchy and the diagnostic yield may be low. You need multiple samples. You may need to go back for more and may even need to get in from the LV because as you know we usually only get RV biopsies in fact it's estimated that you need up to seventeen RV biopsy specimens for eighty percent sensitivity with traditional techniques thankfully the advent of Immuno History Chemistry Electron microscopy molecular typing including viral genome amplification and new techniques like high throughput micro array analysis will help improve sensitivity to biopsy or not to biopsy so the guidelines answer this question by recommending a biopsy in clinical situations when the yield is expectedly the greatest specifically the ACC ESE guidelines. I'll give class when recommendation to plunge those hungry by tomes and of course several ones not the ones from Becker Casper's from episode five into that inflamed my Khartoum into important situations one. If you have a new onset heart failure if less than two weeks duration with human dynamic compromise especially with normal sized or two with new onset heart failure of two weeks or three months duration with dilated lv and electrical instability or failure to respond to the usual care in two weeks. The idea is that these patients probably stand to benefit the most from end of myocardial biopsy because identifying the underlying pathology will guide further management Garcia immunosuppression antivirals and prognosis so. Dan's patient has acute new onset heart failure with a normal left ventricular size and both Hema dynamic and electoral instability. Sounds like a prime candidate for an and Ohio Cardio Biopsy and knowing Dan I know the patient got what he needed. And we're probably about to hear the pathology right again. The Cardio NERD LOVES GETTING INPUT FROM OUR PATH nerd colleagues and we definitely decided to get that biopsy but at the very beginning we were hyper focused on keeping him alive. Perfect that brings us to our step number three manage the acute cardiac injury to ABC's friends are still the ABC's in the EU or rather should I say CB's for circulation airway and breathing either way remember. These patients can present with the scariest and most interesting of the presentations to the CU. Cartagena shock conduction disease with Dangerous Brady Arrhythmias vets with certain cardiac death pericardial fusion with temple. So let's do everything we can to support the patient upfront. Basic Principles for keeping people alive. Apply for Marcus as with any other process including Swan Guided Management Visa Active infusions temporary mechanical circulatory support and temporary pacing is needed management needs to be adjusted to the patient's response and trajectory and we very well involve ultimate durable. Aulad heart transplant or hospice. Care depending on candidacy and patient preferences knowing the pathology will be especially helpful in deciding the ultimate long-term strategy as some causes are more likely to resolve whereas others tend not to but regardless of the acute management. The principles are the same at folks. We will return to fundamentals of shock management in a later episode. But here's how we managed our patient during those initial key moments of full throttle cease. You Care we recognize that this acute presentation and ensuing humid dynamic profile on admission cold. Wet Carta Genyk shot evidence of end organ hypo perfusion. Within Renal failure in conjunction with cardiac biomarker elevation depressed ventricular function and e C abnormalities. All fit the clinical profile of fulminate myocarditis his young age new onset heart failure Cartagena shot and electrical abnormalities. Meant he met. Acc Ha indications for Endo Myocardial Biopsy Ivy wtam in an Ivy Ni- pride were started with initial improvement of his urinary and stabilization of his humor dynamics however they really worsened overnight his mixed venous to went down to forty seven percent. Honestly guys it was a night of rapid decline with this intense nausea electrical deterioration and mechanical breakdown and he continued to have nausea well into the morning. Wow what a clinical course. This is all really making me. Miss My C. You Days Cardio nerds. I love rake down of the acute management and I'm processing what you said about long-term definitive options like L. AD and heart transplant. It really seems like yours would be hard decisions to make in the acute setting when you really don't know how a patient will do. You're absolutely right heather. It's really difficult to know if a given patient will need these advanced strategies but it's helpful to consider the overall natural history of Myocarditis here again makes a huge difference. Lymphocytic myocarditis tends to have spontaneous resolution after the initial insult whereas giant cell myocarditis or. Gce or necrotizing. Houston Philip myocarditis or any. Follow a very different course. Unfortunately with death or transplant being the prevailing outcomes avoiding delays in diagnosis and adequate aggressive management of shock are crucial here and are the reasons we stressed the importance of having a high clinical suspicion. Step one interesting fact. It may be that patients with lymphocytic Myocarditis who develop a foam and of course may just be. Those are the very robust immune system. They're hyperactive immune response surely gets them into a heap of trouble with microdyne and shock but paradoxically it may also help them be more effective in clearing the original vile culprit which may be why some patients with lymphocytic credit is get over it without term problems for patients who overcome the acute phase and avoid death or transplant. The possibilities are either complete resolution or chronic heart failure. It's helpful to review the classic pathologic stages of Myocarditis the foundations of how we understand pathophysiology of viral markers itis come from the classic enter. Virus model beautifully described by Dr Leslie Cooper. In New England Journal Medicine Two Thousand Nine Stage one direct injury from vowel replication or toxin and innate immune response stage to acquired immune response including molecular mimicry and finally staged three either recovery or persistent cardiomyopathy in that last stage the majority of cases we'll have viral clearance and down regulation of the immune response on pathology. You may have complete resolution or varying degrees of replacement fibrosis. Alternatively in a minority of cases the patients may answer more chronic phase of injury with persistence a viral particles and or the immune response resulting in cardiomyopathy heart failure. This is the ultimate fate of about a third of cases. Interestingly ten percent of unexplained dilated cardiomyopathy may be from myocarditis. Perfect Setup Dan. This brings us to the fourth. Major pillar manage the chronic heart equally. That data here is thin because of underdiagnosis and infrequency of Microsoft is but hey the general principles of guideline directed medical therapy of HEF REF for heart failure with Reduced Jack Infraction still apply including life. Saving MEDICATIONS EP. Devices H. O. Fibrillation ablation in selected patients and structural conventions when appropriate so check out our heart. Failure series for review. Pacemakers and defibrillators may be particularly relevant in is given that conduction disease in ventricular. Arrhythmias are a prominent feature of this disease. All right all right. Let's get to the heart of the problem pun intended ten. What did the path show? Corinne ask and you shall receive. We got our patient through the initial shock with our aggressive supportive management. The final pathology showed extensive polymorphism inflammatory cell infiltrate with marked myocytes injury the infiltrate included lymphocytes with extensive CD. Three positively macrophages with extensive CD. Sixty eight positively and some incentive bills and neutrals of note no giant cells were seen. The biopsy was negative for amyloid deposits FIBRO. Ls doses in iron. The conclusion lymphocytic myocarditis amazing. This brings us to the fifth and final pillar. You've got to treat the myocarditis itself. This depends heavily on the pathology so getting to the heart of the path also pun intended never gets old was definitely an important step to immunise oppress or not to immunise a press. That is a new question when it comes to treatment different forms of Cardis are well different. In the treatment of lymphocytic Myocarditis anti treatments have not been shown to improve outcomes while agents against Interleukin. Juan lucan seventeen are still currently under investigation. Steroids are commonly used clinical practice. Even though as it turns out there was no clinical benefit seen in the two RC. Tease that studied their use. However there are two studies that tested the use of combined as afire pre with steroids. That did in fact find improvements in addiction fraction and symptoms. While I D I G has been shown to be effective in children with lymphocytic myocarditis. That hasn't really panned out in adults. There are three ongoing trials in lymphocytic myocarditis. Testing prednisone therapy combination. Iv G and Anna Kendra Anti Interleukin One respectively so conversely Regina Microsoft is if. There's a high suspicion. We usually give a gram of sally mental urgently before diagnostic testing because of how responsive it can be to depression and how early treatment really can change your clinical trajectory. But don't worry ceres will not obscure the results. Once diagnosis is confirmed by biopsy treatment entails a combination of high dose steroids a calcium inhibitor cyclosporin and an anti metabol- as. Thi- mean there also have been some reported benefits to use of settled therapy. Such as rabid derived polychrome against human thymus sites or anti-crime. Globulin in the setting of life threatening GM mechanical circulatory support may be required either as a bridge to recovery or transplantation. Speaking of secretary support sometimes patients will require by ventricular support to stabilize them. Because of by ventricular involvement and initially facilitate procedures like biopsies catheterization unstable ventricular arrhythmias or high grade. Internal blocks can serve as clues. At bye-bye support will be needed. Va can often be a great option in these cases but because they may need prolonged support alternative even support strategy with upper vascular access may allow for physical therapy as we work out recovery or advanced options. We recently had a feminine. Microdyne this patient who was crushed initially onto To balloon pump with. Va but later transitioned to enact celery impelled by five with a right I J. Protect dual are bad with great results. Fortunately unlike lymphocytic Myocarditis G. M. rarely recovers after use of mechanical circulatory support. Gm patients often will require cardiac transplantation reassuringly. Although there are high rates of early rejection post transplant survival is actually similar to those with other cardiomyopathy however to the risk of recurrence after transplant. Gm patients are often maintained on lifelong low dose steroids for those patients who recover without the need for transplant. They'll often need to be maintained on low dose immunosuppression long-term with Myocarditis in the setting of immune checkpoint inhibitors treatments starts with immediately stopping the inciting therapy we usually use high dose. Sarah followed by a taper recommendations also include initiation of NGO tencent receptor blockers or Ten we also sometimes need. They consider device placement in these patients due to the risk of arrhythmias in particularly conduction disease with immune checkpoint inhibitors with necrotizing Philip. Microdyne or any M which may be due to hypersensitivity reaction to certain drugs. It's again important to try and identify the precipitating cause and stop the exposure unlike GM this form of Microdyne will usually respond to high dose steroids as well as the addition of agents. Like Michael. Fennel Mafa Taylor as I pre- similar to GM. Mechanical circulatory support may be needed as a bridge to recovery and in fact this most commonly presents as a new onset by failure with rapid human dynamic corruption these patients are prone to ventricular thrown by and arterial. Mba calling for the possible. Need for up front prophylactic antiquated lesion use however the appropriate strategy for Anti coagulation remains unclear. Guys this has been a absolutely fantastic discussion getting back to my patient for the Cardi Genyk Shock. We initially attempted medical therapy with WTAM However it quickly became apparent that despite our greatest efforts this was not enough to restore adequate perfusion. The patient continue to complain. A profound nausea and was diabetic began to have difficulty with mutation. He also was unable to lie. Flat given his low put state despite medical therapy was initiated with a plan for a left and tripler strategy via impel placement will get to this discussion at another time. His Hospital in Ecuador was complicated by transfusing requirements. Himalayas throughout beside Pina rhabdomyolosis. With acute. Kidney Injury requiring dialysis. But I am so glad to tell you that months later. He left the hospital off dialysis and has made a complete full recovery. I'm literally getting goosebumps as I tell you this right now. We remain close over the years. I wanted to share a message that his wife posted on the one year anniversary from the day of presentation when they returned to the hospital to thank everyone person and this is what she wrote. Sometimes bad things happen. It isn't anyone's fault. They just happen and sometimes you meet the most incredible people who get you through. We can never properly express our gratitude to the staff at the hospital but we are sure we gave it our best shot today. Wow that is such a powerful on special story and a great reminder of the value of the work we do in the hospital and the humanity in our work so we can summarize five points of maximal impulse in approaching myocarditis number one build the clinical suspicion for my occurred itis unique high index of suspicion given the variable presentation and definitely need to keep abroad differential. So you don't miss things like acute coronary syndrome number to decide if an endo myocardial biopsy is necessary. This is most often obtained informative presentations to look for pathologic findings of giants on My Or using a Philip myocarditis because these findings will change management number three manage the acute cardiac injury which can range from initiating supportive care to treatment of shock arrhythmias and even number four manage the chronic cardiac sequentially recovering from the acute phase of. Myocarditis doesn't necessarily mean smooth sailing some develop chronic heart failure warranting. Gd empty what we like to refer to as guideline directed management and therapy as defined by. Dr Randall starling. In episode thirteen and last night reached number. Five the micro. Data's immunosuppression is often started empirically. Informant disease but continuation really depends on what you find on. Pathology thanks everyone for tuning in. We hope you enjoyed our five part approached myocarditis visit. Www DOT cardi nurse dot com to find our microdyne schematic. It's important to share in other successes. So please tell us what's making your heart flutter and send a clip two. Cardi nerds at G. DOT COM before we split like s to enjoy this beautiful message from the real heroes of this episode. Who of course consented to be recorded? I was the patient. My stay at the hospital from what I remember. We'll always be embedded into my memory. The hospital staff was just amazing from the ICU. Staff to the doctors to the nurses to the anesthesiologist to the x Ray techs to everybody who was part of my case. From the time I came to the time I came out of the hospital physical therapists occupational therapists. Some of whom we still communicate with on everyday basis. They say something's happened for a reason. I think that definitely added to our community. Our family community of people at brought us all together and I can't be more thankful for everybody who was case. They gave me an opportunity to meet my son and continue these memories with fable. Hi My name is Julie Miller and in fall of twenty seventeen my husband. Chaz Miller was a patient at Johns Hopkins. Our experience with made a lot better by the care that the staff showed for us. Because it's very scary. You know from my perspective right like I was just in entering the third trimester in pregnant with my second child at two year old at home I had a ten year old stepdaughter with her mom and suddenly their dad is in this position where we don't know if he's going to make it and that is terrible on its own and it could have been a lot worse if we hadn't been really like cared for by the hospital staff. I felt seen. I did not feel overlooked at all. I felt like people were looking at. My husband is a person and the two of us as a family and people really wanted not only to help save him but they wanted to keep me informed. Everyone was pretty aware that I wanted to know what was going on. So I could accurately communicate it to the rest of our extended family. All who really distressed about this and I wanted the information for myself so that I could prepare myself for what may lie in the future and it felt really good to know that there were people who saw us and they allowed me to kind of share who he was and who we were and I felt like he wasn't just a patient to them wasn't just a number. He wasn't just a list of illnesses and injuries. He was a person that they wanted to give life back to wanted him to be able to meet the son that he had gotten to meet yet. They wanted him to be able to go live the best life he could and I can't say enough about nurses and the doctors even from there was a gentleman who've cleaned the WHO was like cleaning up and he would see me all the time and kind of make jokes as I was getting more and more pregnant during the two month period. Uber there and it was just like even that guy like right like he didn't have to talk to me at all but he was so kind to me with. That's when a bad situation can become better and you learn a lot about how to care for other people when they're in times of trouble so very thankful that we got to learn that part about like people just helping people who are down. It was amazing Dan Dan are you muted? God Okay Okay Okay Okay Okay Bye.