Atrial Giant Cell Myocarditis as a Cause of Heart Failure

Figures

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  Figure 1. Echocardiographic Images and Guided Biopsy (A) Transthoracic echocardiography showing biatrial dilatation, wall thickening, and pericardial effusion. Transesophageal short-axis images depict (B) left atrial wall thickening and (C) the left atrial appendage (LAA). Biopsies of the atrial septum and left ventricle (LV) were guided by (DandE) fluoroscopy and (F) transesophageal echocardiography. LA = left atrium; LAO = left anterior oblique; RA = right atrium; RAO = right anterior oblique.

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  Figure 2. “Virtual Histology”: Noninvasive Tissue Characterization With Cardiac Magnetic Resonance (A to I) Ventricle. (AandB) 3-chamber and short-axis views of T2-weighted black blood sequence with no ventricular or pericardial focal edema. (CandD) Color-coded magnetic resonance strain (tagging, fast strain encoded imaging by MyoHealth) with normal longitudinal and circumferential contractility. (AandF) T2- and T1-weighted color-coded quantitative map with no signs of diffuse edema or storage disease. (GandH) 4-chamber and short-axis views without ventricular, or myocardial, or pericardial late gadolinium enhancement (LGE). (I) 3-chamber-view T2-weighted black blood edema image with a bright left atrium and a normal left ventricle (LV). (J to L) Atrium. (J) Short-axis-view with thickening of the left atrium and interatrial septum. (K) Short-axis late gadolinium enhanced left atrium and interatrial septum. (L) 4-chamber view T2-weighted black blood sequence with a bright left atrium, interatrial septum, and right atrium.

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  Figure 3. Histology of Atrial Giant Cell Myocarditis Atrial biopsy revealed necrotic areas, with lymphocytic infiltrations (CD8− and CD4+ cells) and multinuclear giant cells, with positive expression of CD68. (A) Hematoxylin and eosin stain of myocardial biopsy. (B) Period acid–Schiff stain. (C and D) Immunohistochemical staining with CD68 antibody, highlighting macrophages and multinuclear giant cells. (E) CD4+ infiltrating lymphocytes. (F) CD8+ infiltrating lymphocytes.

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  Figure 4. Images and Electrocardiography Before and After Treatment Cardiac magnetic resonance (A to E) before and (G to K) after treatment. (AandG) 3-chamber view T2-weighted image (A) with and (G) without a bright left atrium. (B and H) 3-chamber view cine (B) with and (H) without thickening of the left atrial walls. (AandI) 4-chamber view cine with (C) and (I) without thickening of the atrial walls. (DandJ) Short-axis view of the left atrium (D) with and (J) without thickening of the left atrial walls. (EandK) Short-axis view late gadolinium enhancement (E) with and (K) without enhanced left atrial walls. Electrocardiography showing (F) atrial fibrillation before treatment and (L) sinus rhythm at 3-month follow-up.