Abstract Background Fulminant myocarditis is a rare but life-threatening condition characterised by acute haemodynamic compromise, malignant arrhythmias, and rapid progression to cardiogenic shock. Although the clinical presentation is often uniform, the underlying aetiology is heterogeneous and carries important implications for diagnosis, therapeutic strategy, and prognosis. Case summary We report three patients presenting within months of each other with fulminant myocarditis of distinct aetiologies: eosinophilic myocarditis associated with amoxicillin-clavulanate in a 71-year-old male; lymphocytic myocarditis in a 25-year-old male with a posthumously identified pathogenic FLNC (Filamin C) variant; and lymphocytic myocarditis with extensive replacement fibrosis in a 68-year-old male. All three required mechanical circulatory support. Despite maximal therapy, two patients died and one survived with durable left ventricular assist device (LVAD) support. Conclusion Endomyocardial biopsy was pivotal in establishing the underlying diagnosis and guiding management, particularly in cases where cardiac magnetic resonance imaging (CMR) was technically limited. These cases illustrate that fulminant myocarditis represents a haemodynamic phenotype rather than a final diagnosis. Systematic histological, virological, and – where clinically indicated – genetic evaluation is essential, as aetiology informs management but does not reliably predict outcome in mechanical circulatory support (MCS) -dependent presentations.
Abstract Background ATTRv with the NM_000371.4:c.325G>C, p.Glu109Gln (legacy p.Glu89Gln) mutation, reported in endemic clusters in southern Italy and Bulgaria, is characterized by an aggressive mixed cardio-neurological phenotype. The disease typically manifests around the age of 50. The burden of altered hemodynamics and orthostatic intolerance superimposed on the restrictive cardiomyopathy makes advanced heart failure management a significant clinical challenge. Case summary We present the case of a 59-year-old male with ATTRv amyloidosis carrying the Glu89Gln mutation, alongside type 2 diabetes and macroalbuminuric nephropathy. Despite a genetic diagnosis in 2006 following carpal tunnel syndrome and mild orthostatic hypotension, cardiac involvement was only formally recognized in 2022. Following a period of stability on tafamidis 61 mg/day, he developed weight gain, refractory right-sided acute heart failure and cardio-renal syndrome in 2026. Severe diuretic resistance and hypotension (<95 mmHg) occurred. A large-volume paracentesis (>10 L) was performed and plausibly contributed to the marked improvement of renal function and the restoration of diuretic responsiveness. As a net result of the overall strategy, a 32-kg net weight reduction was achieved over 13 days, leading to discharge in NYHA class II and improvement of Six-Minute Walk Test (6MWT) distance. Discussion Managing congestion in patients with restrictive physiology and susceptibility to hypotension requires multidisciplinary approaches, including unconventional ones, such as evacuative paracentesis. Furthermore, adapting disease-modifying therapies requires careful shared decision-making, balancing the potential benefits of gene silencers with real-world patient preferences and clinical stability.
Abstract Background Rotational atherectomy is crucial for heavily calcified coronary lesions, but complications like burr entrapment, though rare, can be fatal. Case Summary A 55-year-old man with diffuse coronary stenosis underwent rotational atherectomy for a left circumflex artery lesion. During the procedure, the rotational atherectomy burr disconnected from the guidewire, and the wire subsequently disengaged entirely from the burr, leaving the burr retained. A novel wire-entanglement technique was successfully employed by advancing a Fielder XT-A guidewire through the burr's lumen and intentionally knuckling a Sion guidewire to intertwine with it. This maneuver loosened and dislodged the burr, allowing for controlled proximal migration and retrieval into the guiding catheter. Discussion This case presents a rare scenario of complete rotational atherectomy guidewire disengagement from the burr. The successful retrieval using a wire-entanglement technique offers a valuable percutaneous bailout strategy for similar challenging situations where traditional retrieval methods may fail.
