Does this patient with thrombotic thrombocytopenic purpura have a cardiac involvement?

Excerpt

A 53-year-old man was admitted to the intensive care unit (ICU) for thrombotic microangiopathy (TMA). His past medical history included hypercholesterolemia and smoking. In addition to profound thrombocytopenia (7 × 10⁹/l) and mechanical haemolytic anemia (positive schistocytes on the blood smear and negative direct antiglobulin test), he exhibited diffuse purpura on his lower extremities. There was neither chest pain nor clinical features of congestive heart failure, and the electrocardiogram (ECG) was normal. However, cardiac troponin I measurement was 0.45 µg/l. The diagnosis of thrombotic thrombocytopenic purpura (TTP) was immediately suspected, and plasma exchange (PEX) and steroids were initiated within 3 h of ICU admission. The diagnosis was confirmed by undetectable ADAMTS-13 activity on a sample drawn prior to the first PEX. On day 2, the patient presented with atrial fibrillation. An echocardiogram revealed global left ventricular hypokinesis with a ventricular ejection fraction of 25%. Despite treatment intensification (rituximab, twice-daily PEX, pulse steroids and vincristine), the patient deteriorated rapidly and developed cardiac arrest. During cardiac resuscitation, he was asystolic for 45 min before veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated. Coronary angiography was normal. On day 4, there was a slight increase in cardiac function, allowing VA-ECMO to be discontinued. On day 6, the platelet count rose above 150 × 10⁹/l. Clinically; he was neurologically intact, but had delirium. On day 7, heart failure recovered ad integrum. He was extubated at day 11. …