Lyme disease and cardiac sarcoidosis: Management of associated ventricular arrhythmias Jorge Romero, MD, FHRS, Ulrich Jorde, MD, Juan Carlos Diaz, MD,

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Presentation transcript:

Lyme disease and cardiac sarcoidosis: Management of associated ventricular arrhythmias Jorge Romero, MD, FHRS, Ulrich Jorde, MD, Juan Carlos Diaz, MD, Anthony Cioci, MD, Mark I. Travin, MD, Luigi Di Biase, MD, PhD, FHRS HeartRhythm Case Reports Volume 4, Issue 12, Pages 584-588 (December 2018) DOI: 10.1016/j.hrcr.2018.09.001 Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 1 A: A 12-lead electrocardiogram showing a premature ventricular contraction with left bundle branch block (LBBB) morphology inferior axis and transition in V6 suggesting right ventricular outflow tract origin. B: Sustained monomorphic ventricular tachycardia with LBBB morphology, left superior axis probably originating in the basal portion of the right ventricle (RV) free wall. C: Electroanatomical map of the RV revealing extensive fibrosis in the anterolateral and inferolateral RV wall with areas of low voltage extending from the base to the apex of the RV. Unipolar voltage map suggested a larger epicardial substrate (right column). HeartRhythm Case Reports 2018 4, 584-588DOI: (10.1016/j.hrcr.2018.09.001) Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 2 A: 13NH3 perfusion (top rows) and 18F-FDG metabolic (bottom rows) positron emission tomographic (PET) slices. 13NH3 perfusion defects are present in the basal anterior (white arrows), septal (red arrows), and basal and distal inferior (bright green arrows) walls, consistent with scarred regions. Focal 18F-FDG uptake, indicative of inflammation, is present in the anterior wall (turquoise arrows), inferior wall (gold arrows), and septum (orange arrows), as well as the right ventricle (yellow arrows) (note: only selected perfusion defects and focal uptake regions are highlighted). Inflammation in areas of scar, ie, metabolic/perfusion mismatch, is present in the basal anterior (turquoise/white) and septal walls (orange/red arrows). B: Endomyocardial biopsy demonstrating granulomas consistent with cardiac sarcoidosis. C: Transverse PET 18FDG metabolic / computed tomography (CT) fusion images shows focal tracer uptake in the septum and the right ventricle indicative of inflammation, consistent with active cardiac sarcoidosis (left panel). At 3 months (middle panel) after immunosuppressive therapy shows lessening of septal 18FDG PET-CT uptake and near-total resolution of right ventricular uptake, but at 6 months (right panel) shows increased septal tracer uptake and total resolution of right ventricular uptake. HeartRhythm Case Reports 2018 4, 584-588DOI: (10.1016/j.hrcr.2018.09.001) Copyright © 2018 Heart Rhythm Society Terms and Conditions

Figure 3 A: Premature ventricular contraction observed spontaneously at the beginning of the second procedure (left bundle branch block pattern, left superior axis and transition in V6). Epicardial features were not present (maximum deflection index < 55%, intrinsic deflection time 85 ms, and pseudo delta wave < 34 ms). B: Voltage bipolar and unipolar maps of the right ventricle before (pre) and after (post) steroid therapy demonstrating a reduction in the area of fibrosis/scar tissue in the anterolateral and inferolateral right ventricular wall. HeartRhythm Case Reports 2018 4, 584-588DOI: (10.1016/j.hrcr.2018.09.001) Copyright © 2018 Heart Rhythm Society Terms and Conditions