<div>Title: The usefulness of echocardiography in the diagnosis of
myocarditis in a young male after sudden cardiac arrest</div><div>Running head: Echocardiography in the diagnosis of myocarditis</div><div>Authors: Wioletta Sacharczuk, MD, PhD<sup>1</sup>, Rafał
Dankowski, MD, PhD<sup>1</sup>, Andrzej Szyszka MD, PhD,
prof.<sup>1</sup></div><div>Institution. <sup>1</sup>Second Department of Cardiology, Poznan
University of Medical Sciences, Poznan, Poland</div><div>Corresponding author. Wioletta Sacharczuk. Telephone number: +48
+48 666 940 480, fax number:, e-mail address:<i>wioletta.sacharczuk@wp.pl</i></div><div>Abstract: The diagnosis of acute
myocarditis (AM) remains challenging because of its diverse clinical
manifestations. Thus, a wide range of diagnostic tests may be warranted.
Although cardiac magnetic resonance (CMR) is the preferred imaging
technique, it may not be applicable in the acute AM phase. Our case
report highlights the usefulness and diagnostic accuracy of
echocardiographic examination. In the first 2-dimensional
echocardiography, the focal echobright was presented. A reduced value of
global longitudinal strain, and regional disturbances of segmental
myocardial strain, both longitudinal and circumferential, in the
epicardial layer, were detected with a good correlation with CMR
results.</div><div>Introduction. A variety of clinical scenarios makes the diagnosis of
myocarditis a clinical challenge<sup>1</sup>. Among the various
imaging techniques, echocardiography plays an important role in the
diagnostic process<sup>2</sup>, and the analysis of myocardial
strain may be helpful<sup>3</sup>. In this case report, we
highlight the usefulness of echocardiography in the diagnosis of
myocarditis in a young male after sudden cardiac arrest.</div><div>Case description. A 30-year-old patient was admitted to the intensive
care unit after resuscitated sudden cardiac arrest. He lost his
consciousness during an amateur sports competition (a 10-kilometer run).
The patient did not suffer from any chronic diseases. A few days before
the competition he had a cold, but nevertheless decided to take part in
the run. The electrocardiogram on admission revealed Q waves in I, II,
aVF, and in V4 to V6 leads. High-sensitive troponin T and D-dimer levels
were increased (2577 pg/ml (upper reference level: 14 pg/ml) and 2836
ng/ml (upper reference level: 500 ng/ml, respectively). The inflammatory
markers were also above the normal range; white blood cells (WBC) were
14× 10<sup>9</sup>/L and high-sensitive C-reactive protein
(hs-CRP) was 78 mg/l. Point-of-care echocardiography showed hypokinesis
of the apex; the left ventricular ejection fraction (LVEF) was 52%, and
no other pathologies were reported. Both coronary angiography and
pulmonary angiogram were negative. A full echocardiographic examination
repeated on day 7 of hospitalization showed new wall motion
abnormalities including akinesis of the apex, hypokinesis of the apical
and mid segments of the anterior, posterior and lateral walls, and the
apical, mid, and basal segments of the inferior wall. In these regions,
the focal echobright sign was also observed (fig.1). The LVEF was
slightly decreased (48%). Analysis of myocardial strain parameters
revealed decreased global function of the LV; the global longitudinal
strain (GLS) was – 14.4%. Further detailed of-line analysis revealed
normal GLS values in the endocardial layer ( -16.6%) and decreased
values in the epicardial layer (-12.7%) (fig.2). Layer-specific global
circumferential strain (GCS) values were -22.3% for the endocardium and
-9.6% for the epicardium. Analysis of regional strain also showed local
disturbances of both longitudinal and circumferential parameters. In the
epicardial layer, reduced values of the longitudinal strain were
observed in the posterior and lateral walls, in the apical segments of
the inferior and anterior walls, and in the apex (fig.2). In the
endocardial layer, deterioration was observed in the basal and mid
segments of the posterior wall only. Analysis of circumferential strain
at the epicardial layer showed decreased values of the apex, and the
inferior, posterior and lateral walls (fig.3). Cardiac magnetic
resonance (CMR) examination showed edema and hyperemia in the posterior
and lateral wall. According to the Lake Louise criteria (LLc),
myocarditis was diagnosed<sup>4</sup>. After full recovery, the
patient was discharged home with advice to postpone physical activity
for at least 3 months.</div><div>A follow-up examination was conducted after 6 months. Echocardiography
showed persistent akinetic basal segments of the inferior wall and
hypokinetic apical segments of the lateral and anterior walls. The LVEF
was 57%, average GLS -18.6%. The GLS values in the endo- and
epicardial layers were found to have improved (-20.8% and -16.8%
respectively, fig.4). Global circumferential strain values improved in
the endocardial layer but were persistently decreased in the epicardial
layer in the basal segments of the posterior and inferior walls (-29.3%
and -13.6% respectively; fig.5). CMR revealed normal systolic function
(LVEF 55%), and reduced thickness of the basal segments of the inferior
and posterior regions, with high suspicion of necrosis (late
post-gadolinium myocardial enhancement).</div><div>Discussion. In this case report, we showed an additional benefit of
2-dimensional echocardiography in the diagnosis of myocarditis. Firstly,
the focal echobright sign corresponded to the regional left ventricle
contractility disturbances (fig.1). It has been reported in the
literature that the focal echobright is distinctive to the acute phase
of myocarditis only<sup>1</sup>. Indeed, at the 6-month
follow-up, we did not see this phenomenon any more. Furthermore, we
found that the detection of a reduced GLS value, regional disturbances
of segmental myocardial strain, and diminished values of both GLS and
GCS in the epicardial layer, could help to diagnose myocarditis. The
inflammatory process in acute myocarditis is located mostly in the
epicardial layer and mainly in the lateral wall<sup>5</sup>.
Thus, the layer-specific analysis of myocardial deformation could be of
value in the diagnostic process<sup>6</sup>. Myocardial strain
disturbances were confirmed by CMR, which currently plays a major role
in the diagnostic pathway of myocarditis<sup>7</sup>. It has been
shown that the assessment of myocardial strain could be of value in the
diagnosis of myocarditis<sup>8</sup>. More recently, a good
correlation between global and regional strain and CMR has been
demonstrated<sup>9</sup>. In our patient, we found decreased
values of both GLS and GCS, mainly in the epicardial layer. Diminished
GCS was also observed at the follow-up and corresponded to the CMR
results. It has been shown that the circumferential strain, in contrast
to the longitudinal strain, is more sensitive to distinguish scar
transmurality<sup>10</sup>.</div><div>Our case study shows that echocardiography offers several techniques and
modalities which could be very helpful in the early diagnosis of
myocarditis. Although CMR is the preferred imaging technique, it may not
be applicable in the acute phase of the disease. The finding is very
important nowadays, during the COVID-19 pandemic, when the availability
of some procedures may be limited. Thus, the coexistence of the
echobright and myocardial strain abnormalities, especially in the
epicardial layer, may be very useful in the diagnosis of myocarditis.</div><div>Refrences:</div><div>1. Saricam E, Saglam Y, Hazirolan T. Clinical evaluation of myocardial
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