VENTRICULAR TACHYCARDIA AS THE FIRST MANIFESTATION OF GIANT CELL MYOCARDITIS

We report previously healthy 44-year-old male admitted for sustained monomorphic ventricular tachycardia (VT), hemodynamically well tolerated. Echocardiogram revealed moderate left ventricular (LV) dysfunction (LVEF 35-40%). Cardiac biomarkers (hsTnT 8000ng/l, NTproBNP 2900ng/l) were significantly elevated, coronary angiogram was without pathology. Radiofrequency ablation was performed for incessant VT, followed by endomyocardial biopsy. Runs of VT continued and together with administration of beta blockers resulted in prolonged hypotension and low cardiac output syndrome, necessitating inotropic support. His status deteriorated and LVEF dropped to 10%. The patient was transported to our center with confirmed giant cell myocarditis (GCM). Combined immunosuppressive therapy (IST) (azathioprine, prednisone, cyclosporine) was administrated. Within one day, he became electro- and hemodynamically stable and there was no need for mechanical support. Azathioprine was replaced by mycophenolate mofetil. Further recovery was uneventful. Echocardiogram suggested slight recovery of LVEF to 25%. Laboratory tests showed decrease of cardiac markers to almost normal levels. Blood count (including eosinophils) was normal, with persistent elevation of Eosinophilic Cationic Protein (ECP). ICD was implanted and patient was discharged after 40 days on IST and full medication for heart failure. Three months later, the levels of BNP, hsTnT, and also ECP increased again. Due to suspicion for smoldering myocarditis, cyclosporin was switched to tacrolimus and he received bolus of corticosteroids. Control biopsy showed no signs of GSM recurrence. Levels of cardiomarkers and ECP decreased. Until now, the patient is in stable condition, without arrhythmias.