When the electrocardiogram goes quiet: transient low voltage in systemic capillary leak syndrome-associated myocardial oedema—a case report

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  Figure 1. Electrocardiogram obtained at hospital admission, before the development of severe myocardial oedema, showing sinus tachycardia with preserved QRS amplitudes.

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  Figure 2. (A) Electrocardiogram obtained on day 3 before venoarterial extracorporeal membrane oxygenation initiation. Compared with the admission tracing, there is marked diffuse QRS amplitude attenuation with subtle repolarization abnormalities. (B) Transthoracic echocardiography on the same day during mixed shock. Parasternal long-axis view showing marked diffuse myocardial thickening consistent with oedema, with left ventricular wall thickness of up to 20 mm, severe global biventricular systolic dysfunction, and moderate pericardial effusion.

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  Figure 3. (A) Follow-up electrocardiogram obtained after clinical and echocardiographic recovery, showing restoration of QRS amplitudes. (B) Follow-up echocardiography (substernal view) on day 8 showed substantial regression of myocardial oedema and recovery of ventricular systolic function.

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  Figure 4. Cumulative fluid balance and serum lactate concentration during the first 18 days of hospitalization. Marked positive fluid balance accumulated during the extravasation phase because of persistent intravascular depletion. Lactate peaked during refractory shock and declined following venoarterial extracorporeal membrane oxygenation initiation, immunomodulatory treatment, and fluid removal.