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A PICTURE IS WORTH A THOUSAND WORDS
Year : 2023 | Volume
: 24
| Issue : 4 | Page : 227-228
Two-dimensional speckle tracking strain echocardiography in a case of acute myopericarditis due to COVID-19 virus
Ajitkumar Krishna Jadhav
Department of Cardiology, Dr. D. Y. Patil Medical College Hospital and Research Centre, Pune, Maharashtra, India
Correspondence Address:
Dr. Ajitkumar Krishna Jadhav
D. Y. Patil Medical College Hospital and Research Centre, Sant Tukaram Nagar, Pune - 411 018, Maharashtra
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/heartviews.heartviews_68_23
A 38-year-old male presented to the cardiology outpatient department with chest pain and exertional dyspnea for 5 days. His electrocardiogram showed right bundle branch block (RBBB) with a normal cardiovascular examination, and other systems were normal. His echocardiography [Figure 1]a and [Video 1] showed global left ventricular (LV) hypokinesia with moderate LV systolic dysfunction (LV ejection fraction [LVEF] 35%) with normal valves and moderate pericardial effusion (13.4 mm) without tamponade physiology. His LV global longitudinal strain (GLS) was reduced (−9.9%). An initial working diagnosis of acute myopericarditis was made, and the patient was transferred to the ward for further investigations and treatment. According to institutional protocol, COVID-19 reverse transcription–polymerase chain reaction was done, which was positive, along with elevated leukocyte count (17,000/cmm with 45% lymphocytic predominance), elevated cardiac biomarkers with Trop I quantitative 3.1 ng/ml (<0.4 ng/ml), C-reactive protein 64 mg/L (<10 mg/L), creatine kinase-MB 14 ng/ml (0–7 ng/ml), NT pro-BNP 811 pg/ml (<125 pg/ml) with normal laboratory parameters, and cardiomegaly on chest X-ray. Cardiac magnetic resonance imaging [Figure 1]c showed a dilated ventricle with global hypokinesia and moderate LV dysfunction with abnormal patchy subendocardial delayed gadolinium enhancement in the mid and apical anterior and anteroseptal segments s/o myocarditis and moderate pericardial effusion due to acute pericarditis. After taking an injection of remdesivir for 5 days, his fever and other symptoms subsided. Laboratory parameters showed improvement, and subsequent 2D echo with speckle tracking echocardiography strain imaging [Video 2] and [Video 3] showed improved LVEF (60%) and GLS values (−16.6) [Figure 1]b and [Figure 1]d. Subnormal LV-GLS suggests recovery from myocardial injury.
Figure 1: (a)Parasternal long and short axis views in Echocardiogram showing mild pericardial effusion. (b) 2D speckle tracking echocardiography showing subnormal GLS values with reduced GLS in mid myocardial segments. (c) Cardiac MRI showing dilated ventricle with global LV hypokinesia and moderate LV dysfunction with abnormal patchy subendocardial delayed gadolinium enhancement in the mid and apical anterior and anteroseptal segments and moderate pericardial effusion. (d) Echocardiography showing resolution of pericardial effusion during recovery phase of myocarditis 
Discussion 
This case underscores the significance of LV-GLS in diagnosing and predicting cardiac diseases, and its applicability extends to recovery phases as well. LV-GLS stands out as a more objective measure with added prognostic value compared to traditional parameters such as LVEF. Prior research has demonstrated that approximately one-third of patients exhibit improved LVEF following at least 6 months of treatment. Notably, GLS emerges as an independent and supplementary predictor of adverse outcomes in individuals with optimally managed dilated cardiomyopathy, surpassing the established prognostic capabilities of LVEF.[1] Therefore, health-care providers should consider routinely incorporating GLS as a prognostic marker alongside LVEF, especially in patients who experience LVEF improvement or recovery following effective heart failure medical treatment. Recent studies also suggest that changes in LV strain over time may mirror the response to therapy, indicating their potential value in guiding the management of patients with heart failure characterized by reduced ejection fraction.[2] Further investigations are needed to extrapolate this data for predicting cardiovascular events in patients with myocarditis and myopericarditis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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