A case of cardiac sarcoidosis with successful heart transpla
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A healthy 37-year-old female with no past medical history suffered sudden cardiac arrest at home shortly after testing positive for COVID-19. She was found to be in ventricular fibrillation (VF), and return to spontaneous circulation was achieved approximately 1 hour after the arrest. Imaging studies demonstrated extensive consolidation bilaterally suggestive of severe COVID-19 pneumonia/acute respiratory distress syndrome, therefore her cardiac arrest was thought to be secondary to hypoxia. Subsequently, the patient recovered, and a secondary prevention implantable cardioverter defibrillator (ICD) was implanted before discharge.

A few days later, she presented to another hospital with syncope and recurrent ventricular arrhythmias treated by multiple appropriate ICD shocks. ICD interrogation showed 2 ventricular tachycardia (VT) episodes, 20 VF episodes, and a total of 19 40-J shocks delivered, all successful at terminating the arrhythmias. Left heart catheterization showed normal coronaries and left ventricular ejection fraction (LVEF) of 40%. She was taken to the electrophysiology laboratory for an attempt at mapping and ablation of VT which could not be performed successfully due to recurrent episodes of intra-operative VF requiring multiple shocks.

The right ventricular endocardial bipolar voltage maps obtained were suggestive of ARVC (Fig. 1), vs. infiltrative myocarditis. After a failed attempt at VT ablation, the patient was transferred to our institution intubated, sedated, on vasopressor support and IV antiarrhythmic, for possible heart transplant evaluation in the context of ventricular electrical storm.

While admitted to our hospital, repeat imaging studies demonstrated multiple nodules throughout the right lower lobe. An echocardiogram showed LVEF of 35% and moderately decreased function of the RV (Fig. 2C). The patient was managed with amiodarone and lidocaine infusions. Her course was further complicated by cardiac tamponade requiring a pericardial window. With a tentative diagnosis of the ARVC complicated by refractory life-threatening arrhythmias not amenable to mapping/ablation, a heart transplant evaluation was started and the patient was successfully listed as status 3 by exception.

Her episodes of arrhythmia improved, and she was extubated and weaned off lidocaine infusion. The patient's scattered airspace consolidations on repeat images were attributed to resolving COVID-19 pneumonia. She underwent a successful heart transplant 2 months after the initial presentation. The explanted heart showed extensive non-necrotizing granulomatous inflammation and fibrosis diagnostic of CS. The patient had an uneventful post-transplant course and was discharged on immunosuppressive therapy. She was referred for a positron emission tomography (PET) scan to look for extra-cardiac disease.

Source: https://www.journalofcardiologycases.com/article/S1878-5409(21)00134-1/fulltext?rss=yes
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