Cardiothoracic Surgery: Cardiology and Cardiothoracic Surgery |

Cardiac Amyloidosis and Myocardial Bridging: A Double Hit Presenting With Cardiac Arrest FREE TO VIEW

Animesh Gour, MBBS; Kunal Teli, MD; Gerald Hollander, MD; Karishma Kitchloo, MD
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Maimonides Medical Center, Brooklyn, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;149(4_S):A48. doi:10.1016/j.chest.2016.02.051
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SESSION TITLE: Cardiology and Cardiothoracic Surgery

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM

INTRODUCTION: Amyloidosis usually presents with symptoms of heart failure. Infrequently, it can present as exertional syncope and sudden cardiac death. The effects can be magnified in the presence of myocardial bridging

CASE PRESENTATION: A 31 years old male was brought to the emergency department by EMS for cardiac arrest after he collapsed in the field while running a marathon. As per EMS records, patient received about two minutes of cardiopulmonary resuscitation before he had a shockable rhythm and subsequent return to spontaneous circulation. In the emergency department (ED), he was intubated for acute respiratory failure. Patient's medical history was significant for only attention deficit hyperactivity disorder for which he was taking methylphenidate. Initial laboratory values were consistent with post cardiac arrest, viz. elevated troponins, hyperkalemia, mild acidosis, and mild leukocytosis. Initial electrocardiogram showed sinus tachycardia with borderline ST segment depressions and tall T-waves in the anterolateral leads. Chest X-ray was suggestive of mild pulmonary congestion. An echocardiogram done in the ED was near normal with a preserved ejection fraction of 50% with some hypokinetic apical lateral and basal inferior segments. On day 2, most of the lab values normalized with improvement of the EKG as well as the chest X-ray. The patient was extubated successfully on day 2. A work up was initiated for the etiology of the cardiac arrest, with initial suspicion for arrhythmogenic right ventricle dysplasia and abnormal coronary anatomy. A MRI of the heart was done which showed diffuse delayed enhancement of the left ventricle myocardium with inability to nullify the blood pool, suspicious for amyloid cardiomyopathy. A CT angiogram of the heart showed a 2-cm segment of myocardial bridging in the mid left anterior descending artery without any evidence of coronary artery disease. In view of these findings, the patient was scheduled for an abdominal fat pad biopsy, which showed yellow/green birefringence under polarized microscopy with a Congo red stain.

DISCUSSION: Amyloidosis of the heart usually presents with symptoms of heart failure. But, rarely, it can present with syncope or sudden cardiac death and is usually associated with poor survival1. Although myocardial bridging has been found to have a prevalence of close to 25%, they are of little clinical significance. However, severe bridging of the major coronary arteries has been reported to predispose a patient to sudden cardiac death2.

CONCLUSIONS: Although rare, amyloidosis and symptomatic myocardial bridging should be considered in the broad differential of sudden cardiac death, in young adults.

Reference #1: Chamarthi B. et al. Features and prognosis of exertional syncope in light chain associated AL cardiac amyloidosis. Am J Cardio. 1997;80(9):1242

Reference #2: Husmann L et al. Myocardial bridging causing infarction an ischemia. Eur Heart J. 2011;32(7):790

DISCLOSURE: The following authors have nothing to disclose: Animesh Gour, Kunal Teli, Gerald Hollander, Karishma Kitchloo

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