Bidirectional Ventricular Tachycardia in a Patient With Fulminant Myocarditis Secondary to Cardiac Sarcoidosis Mimicking Giant Cell Myocarditis

Figures

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  Figure 1. Progression to bidirectional ventricular tachycardia: (A) Baseline electrocardiogram upon admission to hospital shows sinus rhythm with a left bundle branch block and left-axis deviation. (B) Recurrent runs of nonsustained monomorphic ventricular tachycardia first morphology (VT1) (∗) (—right bundle left superior axis) with atrioventricular (AV) dissociation. (C) Sustained monomorphic ventricular tachycardia second morphology (VT2) (+) (right bundle right inferior axis) with AV dissociation, and a fusion beat (^). (D) Recurrent runs of bidirectional ventricular tachycardia with the alternating morphologies matching prior VT1 (∗) and VT2 (+) and with AV dissociation with various capture and fusion beats (^).

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  Figure 2. (A) Multifocal myocarditis: Shown is a microscopic presentation of endocardial biopsy from our patient showing multifocal myocarditis with multi-nucleated giant cells and many inflammatory cells, including lymphocytes, plasma cells, and eosinophils. (B) Granulomatous inflammation: Shown is a microscopic presentation of the pathologic analysis of the explanted heart—well-formed granulomas with asteroid bodies consistent with a diagnosis of cardiac sarcoidosis. (C) Gross cross-sectional pathology of explanted heart: clear scar can be seen at the basal left ventricular septum, extending from the posterior wall to the anterior wall, with proposed exit sites of ventricular tachycardia first morphology (VT1) (∗), inferoseptal basal left ventricle, and ventricular tachycardia second morphology (VT2) (+) anterolateral basal left ventricle.