Does it fit into AFM??
Libermann et al (1991)
Clinical & Echocardiographic criteria for ‘Acute Fulminant
Developed acute and severe heart failure during this illness
Evidence of Left ventricular dysfunction on Echo (EF< 40%)
Recent history of viral prodrome with fever lasting < 2 weeks
No previous or family history of cardiomyopathy
Acute heart failure:
Fatigue, breathing difficulty or edema developing during a 1-2 day
period and within 7 days prior to hospitalization
Non- Obstructive TAPVC ??
Why not ??
Short history with a ‘not-so-impressive’ fever
CXR – Bilateral white-out
ECHO (on D1 hospital stay)
RA & RV grossly dilated
12 mm ASD with R L shunt
Mild TR and PR
Almost all ABGs (except one) showing PaO2 < 80
Clinical SpO2 – fluctuating; ?Pulmonary reactivity
What we could have done?
12 lead ECG
Caveats of echocardiography in TAPVC
One of the most difficult-to-diagnose conditions on ECHO
Serial Echo evaluations required – most often
Specific expertise in pediatric echocardiography required
CLARIFICATIONS REGARDING ECHOCARDIOGRAPHY
• Consultant Echo could have been considered in this case?
• Echo done for myocarditis ? Information regarding
contractility/ Ejection fraction ? If normal, how does that
correlate with our clinical picture?
SEPSIS: Points in favor
Pneumonia (bilateral infiltrates) + Myocarditis + elevated OT/PT
Nosocomial sepsis – COEXISTING?
Outside hospital stay – 1 day
Multi-drug resistant Acinetobacter
Isolated from Blood c/s within 48 hours of admission
What precipitated the illness in the first place??
Rickettsial infection / Leptospirosis ruled out
Viral causes more likely?
What does available literature say?
1. Coxsackie virus
Can produce this kind of a clinical presentation
Most important causative agents for Acute Fulminant Myocarditis
Management of shock
First documentation of CVP at 26 hours of hospital stay
Refractory to most measures (Fluid + Ionotropes)
Cause of refractory shock ?
Most precipitating causes ruled out
Hydrocortisone shock dose given
Acute Fulminant Myocarditis
Most of the recent reviews on Myocarditis in
Infants and neonates – report use of LVAD or
ECMO for refractory cardiogenic shock
secondary to Acute fulminant Myocarditis
Post Mortem Biopsies
Was Myocardial biopsy considered?
AHA recommendation in all clinically suspected myocarditis*
EMB Vs Cardiac MRI
Was any other biopsy carried out? If yes, what do the findings
Summary of queries
Was TAPVC considered as a possibility in this child?
Why was 12 lead ECG not considered?
How do we explain the echocardiographic picture in the setting
of AFM ? (Apparently normal ejection fraction)
Shock management – Comments?
Post mortem biopsy reports