P2.096: Sleeping Scars, Sudden Storm: Recurrent Dilated Cardiomyopathy in an Adolescent Requiring Intensive Care

Introduction: Dilated cardiomyopathy (DCM) in children is most often idiopathic or related to post-viral myocarditis, with many patients recovering fully following medical therapy. Recurrence of DCM after years of normalized function is extremely rare. We present a unique case of recurrent DCM in an adolescent female, more than a decade after initial recovery, who presented in cardiogenic shock requiring pediatric ICU-level care.

Case Description: The patient presented with progressive exertional dyspnea and cough over several months, culminating in acute heart failure requiring Pediatric Intensive Care Unit (PICU) admission. At presentation, she had New York Heart Association (NYHA) Class IV symptoms, including shortness of breath at rest and orthopnea. Initial echocardiography showed a dilated left ventricle and severely reduced ejection fraction (EF ~30%). She was treated with a milrinone infusion alongside guideline-directed medical therapy (GDMT), including sacubitril-valsartan, spironolactone, dapagliflozin, furosemide, and carvedilol.

During her PICU stay, she experienced frequent multifocal premature ventricular contractions (PVCs) and short, non-sustained runs of ventricular tachycardia (VT), which decreased following the weaning of milrinone. Cardiac MRI revealed findings consistent with dilated cardiomyopathy and linear mid-wall late gadolinium enhancement (LGE), suggesting underlying myocardial fibrosis and potential prior myocarditis. The patient had a significant cardiac history of presumed viral myocarditis at 10 days old, requiring prolonged reverse remodeling therapy until the age of two, after which her cardiac function normalized and she remained asymptomatic until several months before the current episode.

Post-discharge, she was transitioned to metoprolol and continued on GDMT. Her EF improved to 50% with resolution of heart failure symptoms and improved exercise tolerance. Despite clinical improvement, Holter monitoring showed ongoing multifocal PVCs and brief non-sustained VT. Electrophysiology consultation did not recommend an implantable cardioverter-defibrillator (ICD) at this time, but close monitoring remains warranted.

Discussion: This case highlights the importance of recognizing late recurrence of DCM, even after apparent clinical resolution. Myocardial fibrosis identified by LGE may represent a substrate for arrhythmia and disease relapse. The patient's PICU course required tailored hemodynamic support and arrhythmia surveillance, underscoring the complex interplay between myocardial function, electrical instability, and critical care decision-making. Longitudinal follow-up and reevaluation of device candidacy are key given the evolving risk of sudden cardiac events.

Conclusion: Recurrent pediatric DCM, especially after prolonged remission, is rare. In the PICU, timely recognition and aggressive management of decompensated heart failure, alongside advanced imaging and arrhythmia monitoring, are essential. This case emphasizes the need for multidisciplinary care, long-term surveillance, and readiness to reassess treatment strategies as patients transition through stages of recovery.