Venoarterial extracorporeal membrane oxygenation support for acute fulminant myocarditis

Type of funding sources: None.

Acute fulminant myocarditis (AFM) may be life threatening. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can provide an effective cardiocirculatory support.

This study aims to evaluate the clinical course and the prognosis of patients (P) with fulminant myocarditis supported by VA-ECMO.

Observational retrospective single-center study of 15 consecutive P (73% women; 45,6±11,6 years; body mass index 26,7±2,23kg/m2) admitted to an intensive care unit (ICU) for AFM managed by peripheral VA-ECMO between 2008 and 2018. Were included P with diagnosis of myocarditis, recent onset of symptoms and severe hemodynamic compromise within 7 days following hospital admission. P were followed during 29,4±8,4 months after discharge to identify rehospitalization due to cardiovascular causes (re-hosp), recurrence of myocarditis or death.

The P had previous history of hypertension (20%), diabetes (13%), dyslipidemia (20%), autoimmune disease (7%), previous acute myocarditis (7%), 20% were former smokers and 7% active smoker. The main clinical presentation was chest pain (27%), dyspnea /heart failure (47%) and epigastric pain/nausea (13%). The media between symptom onset and hospitalization was 14,9±6,5 days. The total hospital length of stay was 37±6,9 days, with 18,7±16,1 days in the ICU. During hospitalization, arrhythmias were documented in 40%: atrial fibrillation/flutter (13%), complete atrioventricular block (13%), ventricular tachycardia (13%), ventricular fibrillation (7%), asystole (7%) and electrical storm (7%). Medical therapy included corticosteroids in 47% of P, immunosuppressive therapy in 13% and intravenous immunoglobulin in 13%. The mean duration of VA-ECMO support was 8,5±6,2 days. 27% had preserved left ventricular systolic ejection fraction (LVEF), 13% left ventricular dilation, 13% pericardial effusion and 13% late gadolinium enhancement. The mean LVEF was 23±8,2%. Endomyocardial biopsy was diagnostic for 3 out of 4P in which was performed. The etiology of myocarditis was identified in 60% of P: viral (33%), autoimmune (7%) and pheochromacitoma (20%). During hospitalization 5P (33%) died (3 in the ICU). The P who died had higher liver sequential organ failure assessment (SOFA) and kidney SOFA scores before starting ECMO, both being predictors of mortality (liver SOFA:Cramér’sV 0,76;95%CI 0,009-0,014;p=0,01;kidney SOFA:Cramér’sV 0,79;95% CI 0,03-0,04; p=0,031). At discharge, the survival rate was 67% and the recovery of LVEF ocurred in 47% of P. During follow-up, there were no re-hosp, recurrence of myocarditis or deaths and 53% of P had preserved LVEF.

AFM is associated with high mortality rates. Percutaneous VA-ECMO is a highly effective haemodynamic support that can be used as a "bridge to recovery". Once a patient recovers, the subsequent clinical outcome seems favourable.