Diagnosis of Myocarditis by Cardiac Tissue Velocity Imaging in an Olympic Athlete
A 31-year-old professional cyclist (former Olympic and world champion) presented with 2 episodes in the previous 2 weeks of nonsustained (suspected as supraventricular) tachycardias with dizziness during road cycling competition. In the exercise ECG during cycle ergometry (increasing by 50 W every 3 minutes until 1 minute of 500 W was reached at exhaustion), a total of 7 monotopic ventricular extrasystoles at the first exercise stages was the only abnormality seen. A first Holter ECG over 22 hours, including a 4-hour training session without complaints, showed ≈1000 monotopic ventricular extrasystoles, including 7 ventricular couplets, which were more frequent during exercise. The one- and two-dimensional echocardiography, including color and pulsed wave Doppler, showed no abnormalities (see Movie). The left ventricular end-diastolic diameter was 57 mm with normal systolic (fractional shortening 35%) and diastolic (maximal early to late diastolic transmitral velocities, E/A) function without regional wall motion disturbances. The result of a second Holter monitoring during the next cycle competition (performed by the athlete against medical advice) is shown in Figure 1, revealing a symptomatic long-lasting ventricular tachycardia at a frequency of 250 to 200 per minute. In the cardiac tissue Doppler, a net loss of systolic regional wall velocities was evident (Figure 2). Cardiac magnetic resonance did not reveal a pathological finding. Finally, the diagnosis of chronic myocarditis was confirmed by myocardial biopsies. Figure 1. Holter ECG during cycle race showing a 45-minute-long ventricular tachycardia at a frequency of 250 (first minute) to 200 per minute. Figure 2. Cardiac Doppler tissue velocities of interventricular septum and left ventricular lateral wall (2 heart cycles of the left ventricle in the 4-chamber view; the curves on the right correspond to the sample volumes of the same color, respectively, on the left). The arrows show decreased to paradoxical velocities during systole in the medial and distal lateral wall segments.
The diagnosis of myocarditis still requires myocardial biopsy; we suggest, however, that cardiac tissue velocity imaging is a promising, noninvasive method for helping to decide whether cardiac catheterization is necessary, especially in patients without typical symptoms of myocarditis.
The Movie is available in the online-only Data Supplement at http://www.circulationaha.org.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
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