Recurrent Granulomatous Myocarditis after Heart Transplant

Abstract

Introduction Recurrent granulomatous myocarditis is an uncommon phenomenon after heart transplantation. We present a case of late recurrent granulomatous myocarditis after heart transplant. Case Report A previously healthy gentleman presented with complete heart block requiring placement of a permanent pacemaker. He subsequently developed reduced left ventricular function and progressive heart failure, prompting an endomyocardial biopsy which revealed granulomatous myocarditis. He was treated with steroids but his symptoms progressed and ultimately underwent orthotopic heart transplant. Pathologic examination of the explanted heart revealed “Florid granulomatous inflammation throughout the myocardium, with dense scar that is patchy and irregularly distributed.” 7 Years after transplant he developed severe rapid onset heart failure symptoms. Transthoracic echocardiography revealed a newly reduced left ventricular ejection fraction of 35 %. Urgent catheterization and endomyocardial biopsy was performed revealing mild single vessel allograft vasculopathy, mildly elevated filling pressures and a cardiac index of 2 liters per minute per meter squared. Pathologic examination of the biopsy revealed myocardium with significant inflammation including numerous eosinophils and scattered multinucleated giant cells with myocyte damage. Cardiac magnetic resonance imaging (CMR) was performed revealing late gadolinium enhancement in the apical lateral, and basal anteroseptal walls [Figure] with prolonged T2 time suggestive of edema. He was treated with high dose steroids, intravenous diuretics were administered, and he clinically recovered symptomatically and continues to follow in clinic. Summary Granulomatous myocarditis caused by giant cell myocarditis or cardiac sarcoidosis can lead to end stage heart failure and necessity for heart transplant. Recurrence of the granulomatous inflammation can lead to graft dysfunction and can be identified by endomyocardial biopsy as well as noninvasive imaging with CMR.