2 Cardiology Research and Practice 15/10/2009 18:27:27 V 5 10 Figure 1 2 cm A screen for cardiomyopathy revealed normal iron levels, thyroid function, magnesium, zinc, ceruloplasmin, and immunoglobulins. His angiogram revealed unobstructed coronaries with no evidence of thrombosis and no disease that would explain his regional wall motion abnormalities, good compaction on ventriculography, and an ejection fraction of 40%. Reversible causes of cardiomyopathy were considered and excluded, and there was no history of an infective viral precipitant. The combination of a negative cardiomyopathy screen so far and the lack of an infective cause, made a pro- gressive condition most likely as his symptoms progressed. He improved symptomatically and was seen two weeks later by the electrophysiology team, who organised an MRI that revealed both left and right ventricular dilatation with moderate biventricular impairment and scarring. An outpatient 24-hour tape revealed a sinus bradycardia with almost 19,000 ventricular ectopics, including couplets and triplets but no ventricular tachycardia. An image of his cardiac MRI on 2D scar weighting is shown in Figure 2 with scarring and biventricular dilatation. An implantable cardiac deﬁbrillator was discussed and the patient chose to go away and consider his options. The option of a life vest deﬁbrillator was not considered at that point as it was felt that the patient needed to weigh up the eﬀect of any deﬁbrillator, and if he were to reject an implantable version then the lifevest system would be oﬀered. His medical treatment remained the same comprising of aspirin, bisoprolol, simvastatin, and ramipril. 3. Second Admission He was readmitted 6 weeks later with increasing frequency of palpitation and debilitating dizziness. During his admission, Figure 2 he had frequent runs of VT with occasional haemodynamic compromise before cardioverting on his own. As the patient’s blood pressure was only ever just above 100 mm/hg, we were unable to increase any of his heart failure treatment. He underwent left and right heart catheterisation and endomyocardial biopsies at the local specialist centre before he had an ICD inserted. The left heart catheter was repeated as the team at the specialist centre felt the rapidly progressive nature of his course merited exclusion of coronary artery thrombus formation. The left heart catheter showed normal coronary arteries again, and the right ventricular systolic pressure was 25 and the pulmonary capillary wedge pressure was 10.