270 PARTICULAR MISDIAGNOSED ACS-NSTEMI IN A YOUNG ADULT WITH HISTORY OF HODGKIN'S LYMPHOMA IN THE ERA OF FREQUENT SARS-COV2 RELATED MYOCARDITIS: NOTHING SHOULD EVER BE LEFT TO CHANCE.
Authors: Luca Emilia De , D´angelo Claudio , Ponturo Gianluca , Pasquale Giovanni San 
Published: December 2022

Abstract

Background
Radiotherapy plays a key role in the multimodality treatment of thoracic tumors. Radiotherapy-induced heart disease (RIHD) has become an increasingly recognized adverse reaction contributing to major radiation-associated toxicities, including nonmalignant death. Especially patients with diseases with excellent prognosis, such as breast cancer or Hodgkin's lymphoma, may suffer from delayed side effects 2-6 including RIHD in a dose-dependent manner. The pathological spectrum of RIHD includes conduction abnormalities, valvular disease, coronary artery disease, pericarditis and pericardial constriction or effusion, cardiomyopathy, and myocardial fibrosis. Here we describe the case of a young man cured of Hodgkin's lymphoma who presented to our laboratory with the diagnosis of suspected myocarditis in the Sars-COV 2 era, but the presenting clinical picture confused the clinicians and complex coronary artery disease was behind it.

Method-Clinical Case
A young 33-years-old man presented to the emergency room with typical exertional chest pain. Clinical history: smoker patient who denied familiarity for cardiovascular diseases, dyslipidemic, 10 years previously underwent chemotherapy and radiotherapy for Hodgkin's Lymphoma in complete remission. A nasopharyngeal molecular swab for Sars-COV 2 was performed, which was negative. The presentation electrocardiogram (EKG) documented nonspecific repolarization abnormalities; the myocardionecrosis enzyme curve performed at three times was frankly positive with elevated PCR values ​​(102 pg/ml). Color Doppler echocardiography documented a left ventricular ejection fraction at the lower limits of normal, hypokinesia of the mid-basal segments of the infer-posterolateral wall with moderate mitral valve regurgitation. On suspicion of acute myocarditis, the patient was transferred to the Coronary Care Unit and, during admission, underwent MRI, which showed a slightly enlarged left ventricle (DTD 58 mm, EDV 147 ml), slightly depressed systolic function (LVEF 46%), akinesia of the proximal lateral and mid-proximal wall. In delayed enhancement sequences late persistence of gadolinium in the endomesocardium (60%), proximal lateral and mid-proximal wall with involvement of areas adjacent to the base of implantation of both papillary muscles. In light of the instrumental picture, the patient underwent coronarography, which showed an unexpected nightmare picture, given his young age. Circumflex branch (lcx-lesion culprit) suboccluded to the middle segment with TIMI I downstream flow at the bifurcation with a prominent obtuse marginal branch (OM) with a delayed reperfusion (Medina 1,1,1); diffusely atheromatous left anterior descending artery (LAD), showing 70% complex critical disease in the proximal segment at the bifurcation with a first diagonal branch of good caliber and good distribution area (Medina 1,1,1).

Clinical resolution/Results
Therefore, in a patient with misdiagnosed ACS-NSTEMI, two complex coronary bifurcation angioplasties according to TAP technique (Fig 3-4) were performed through left radial access with Slender 7 in 6 introducer at one time. The following drugs were administered in the cath-lab: Cangrelor bolus/kg followed by continuous infusion for 2 hours and Prasugrel 60 mg, initially UFH 5000 IU and anticoagulation control according to ACT during the procedure. The procedure ended with complete revascularization and asymptomatic patient. During the following days of hospitalization, no late electrical or mechanical complications occurred.

Conclusions
The one just described represents a complex and unexpected scenario for a young adult. The literature available has analyzed the pathophysiology of myocardial damage resulting from exposure to high amounts of radiation in patients undergoing curative radiotherapy for Hodgkin's lymphoma. It is now generally accepted that the most common clinical syndromes after irradiation are pericarditis in acute and chronic forms,. However, coronary vessel lesions have been considered exceptionally rare, so the true pathophysiological triggering mechanism is still poorly understood. The most widely accepted hypothesis on the onset of RICHD is a dual pathway of vascular damage ("two-hit combined hypothesis"). The most important preventive measure regarding RICHD is dose minimization. Few data are available in the literature on outcomes according to the revascularization strategy adopted in patients with RICHD (PCI vs. CABG). Morbidity and mortality from post-radiotherapy cardiovascular complications in patients with Hodgkin's lymphoma must be reduced through close cardiological surveillance in primary prevention and a close collaboration between oncologists and cardiologists in order to minimize any deleterious complications, especially in the young. Further research is needed to elucidate profibrotic mechanisms, identify promising therapies that can be implemented early during the course of treatment and to compare revascularization strategies with longer-term mortality in such patients, in order to guide the physicians in the decision-making.