‘Green Apple’ Heart Failure

Abstract

CASE REPORTA 76-year old hypertensive gentleman was referred to the Department of Cardiology for treatment of complete atrioventricular (AV) block. At the initial physical examination, blood pressure was 115/67 mmHg and heart rate was 45 beats per minute (bpm). Mild oedema was noticed in the lower extremities. Chest X-ray showed enlarged cardiac silhouette, with interstitial oedema. At echocardiography, there was marked concentric left ventricular hypertrophy. The initial diagnosis was heart failure triggered by AV block, complicating severe hypertensive heart disease. The patient's condition quickly improved with intravenous diuretics and he was discharged after the placement of a sequential AV pacemaker. He was re-hospitalized one month later for a new onset heart failure. A thorough re-evaluation of the clinical data was then performed. A sharp contrast was noticed between the low QRS amplitude in the frontal derivations and the marked left ventricular (LV) wall thickness on the echocardiography (Fig. 1). A sparkling of the LV walls was also noticed, along with a Doppler restriction pattern of the mitral flow and prominent dilation of both atria. Therefore, cardiac amyloidosis was suspected and additional examinations were performed.Myocardial 99Tc-dicarboxypropane diphosphonate (DCDP) scintigraphy showed marked myocardial uptake of the tracer (Fig. 2). Late global subendocardial enhancement was noticed at magnetic resonance imaging [MRI] (Fig. 3). Eventually, right ventricle endomyocardial biopsy was performed. Routine haematoxylin-eosin staining showed large areas of amorphous substance between the cardiac myocytes, which were predominantly stained by Congo red,