Successful Bridge-to-Recovery Treatment in a Young Patient with Fulminant Eosinophilic Myocarditis: Roles of a Percutaneous Ventricular Assist Device and Endomyocardial Biopsy

Figure 1. Electrocardiogram on admission. Electrocardiogram shows tachycardia, sinus rhythm, right axis deviation, nonspecific ST-T change, and clockwise rotation.

Figure 2. Findings on admission and after Impella placement. (a) Pre-Impella placement chest radiograph shows prominent pulmonary edema with an enlarged cardiac shadow. (b) At admission (pre-Impella placement), echocardiography, parasternal long-axis view, shows an extensively thickened left ventricle with enhanced echogenicity and a modest amount of pericardial effusion [left-ventricular ejection fraction (LVEF) 42%]. (c) Post-Impella placement chest radiography shows less pulmonary edema. (d) Post-Impella placement echocardiography, parasternal long-axis view, shows Impella inlet parts with an acoustic shadow in the proper position (yellow arrow) (LVEF 27%). (e) At discharge, chest radiography shows an almost normal cardiac shadow. (f) At discharge, echocardiography, parasternal long-axis view, shows improved contractility without pericardial effusion (LVEF 60%).

Figure 3. Histological findings of right-ventricular endomyocardial biopsy specimen on admission. Hematoxylin-eosin staining (formalin-fixed; paraffin-embedded) shows damaged myocardium and infiltration of degranulated eosinophils (arrow, right), lymphocytes, and neutrophils. (a) ×20. (b) ×60.

Figure 4. Changes in blood markers during hospitalization. Graphs showing changes in serum troponin I and creatine-kinase concentrations, white blood cell and eosinophil counts, plasma brain natriuretic peptide, serum C-reactive protein, serum creatinine, and serum aspartate amino transferase concentrations, together timing of with mechanical circulatory support and immunosuppressive therapy. PVAD, percutaneous ventricular assist device; m-PSL, methyl-prednisolone; PSL, prednisolone.

Figure 5. Thallium-201 and iodine-123 β-methyl-p-iodophenylpentadecanoic acid dual-tracer myocardial scintigraphy 3 weeks after admission. Slight patchy deficit was found for myocardial thallium uptake in the anterolateral wall and further decreased uptake of BMIPP, which was consistent with a mild perfusion-metabolism mismatch (white arrows). (a) Long-axis 2D view. (b) Short axis 2D view. (c) Polar map. 2D, two-dimensional; ANT, anterior; INF, inferior; TL, thallium.

Figure 6. Cardiac 1.5-T magnetic resonance imaging 4 weeks after admission. (a) T2-weighted black-blood images show no significant high-intensity signal. (b) Late-gadolinium enhancement shows no significant focal high-intensity signal. (c) Native T1 mapping analysis shows mildly elevated values: (1) anterior wall, 1193.01±36.34 msec, (2) septal wall, 1193.05±32.03 msec, and (3) posterolateral wall, 1198.87±42.86 msec.