P313 AN UNUSUAL CASE OF SEVERE LEFT VENTRICULAR DYSFUNCTION: MILANESE ‘BREAKING BAD‘

A 39–year–old Filipino man was admitted for dyspnea and lower limb edema for about a month, in combination with stable cardiac enzymes movement (TnT 128>78>115 ng/dl), fluctuating unspecific inflammatory profile and hepatic impairment. Trans–thoracic echocardiography confirmed heart failure (HF) in a setting of eccentric left ventricular hypertrophy, diffuse hypokinesia and severe global functionreduction. Despite the absence of typical chest pain, the presence of cardiovascular (CV) risk factors (DMT2, smoking, dyslipidemia), previous alcoholism and the finding of widespread ventricular repolarization ECG changes seemed to suggest an ischemic or multifactorialorigin of the HF. After the finding of a critical trivascular coronary artery disease on coronarography and a pulmonary nodule on chest CT, the cardiac magnetic resonance (CMR) confirmed the diagnosis of severe dilated HF with evidence of a diffuse wall signal hyperintensity in STIR sequences and a intramyocardial and subepicardial patchy LGE pattern of non–ischemic meaning. The possible ischemic etiology was thus overlaid with an inflammatory disease, leading to assume sarcoidosis or myocarditis be the cause of HF. The main screening tests (ACE and immunologic–infectious profile) were negative a a PET/CT scan confirmed a diffuse cardiac inflammation with no focal hypercaptant lesions. Therefore, sarcoidosis was ruled out, and an endomyocardial biopsy (BEM) was performed, and resulted, however, inconclusive. Following, an unexpected finding revealed through a more scrupulous anamnesis: a long–time abuse of a methamphetamine (MDMA) prevalent in the Filipino community called Shaboo. This type of MDMA is accompanied by multiple CV system impacts, including MDMA–associated cardiomyopathy (MACM), a clinical picture compatible with the findings obtained by CMR and BEM performed. After discussion in Heart Team and therapeutic optimization, the patient was candidate for coronary artery bypass. Thus, with the correct diagnostic definition and treatment of HF triggers, an improvement in clinical and left ventricularfunction was marked (EF 45%). Monitoring will allow evaluation of the evolution of the changes found at CMR and will document eventually reversibility of MACM after protracted abstention from MDMA abuse.