Successful Treatment of Novel H1N1 Influenza related Fulminant Myocarditis with Extracorporeal Life Support

Background. Treating myocarditis can be difficult, as clear criteria for diagnosis and management are lacking for heterogeneous clinical presentations. Case Description. We report a case of a 49-year-old female who presented with cardiogenic shock and subsequent cardiac arrest. Extracorporeal life support was instituted, and after eight days with Impella CP the patient recovered and at six months presented with normal cardiac function. Conclusion. Fulminant myocarditis remains a challenging disease in daily clinical practice, not only for diagnosis, but also for treatment. With this report we emphasize that myocardial failure due to fulminant myocarditis may be reversible if treated with extracorporeal life support, which thus plays an important and life-saving role.

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Recognition and Initial Management of Fulminant Myocarditis

Circulation ◽

10.1161/cir.0000000000000745 ◽

2020 ◽

Vol 141 (6) ◽

Cited By ~ 46

Author(s):

Robb D. Kociol ◽

Leslie T. Cooper ◽

James C. Fang ◽

Javid J. Moslehi ◽

Peter S. Pang ◽

...

Keyword(s):

Life Support ◽

Extracorporeal Life Support ◽

Disease Process ◽

Ventricular Assist Devices ◽

Fulminant Myocarditis ◽

Circulatory Support ◽

Orthotopic Heart Transplantation ◽

System Failure ◽

Delay In Diagnosis ◽

Disease Specific

Fulminant myocarditis (FM) is an uncommon syndrome characterized by sudden and severe diffuse cardiac inflammation often leading to death resulting from cardiogenic shock, ventricular arrhythmias, or multiorgan system failure. Historically, FM was almost exclusively diagnosed at autopsy. By definition, all patients with FM will need some form of inotropic or mechanical circulatory support to maintain end-organ perfusion until transplantation or recovery. Specific subtypes of FM may respond to immunomodulatory therapy in addition to guideline-directed medical care. Despite the increasing availability of circulatory support, orthotopic heart transplantation, and disease-specific treatments, patients with FM experience significant morbidity and mortality as a result of a delay in diagnosis and initiation of circulatory support and lack of appropriately trained specialists to manage the condition. This scientific statement outlines the resources necessary to manage the spectrum of FM, including extracorporeal life support, percutaneous and durable ventricular assist devices, transplantation capabilities, and specialists in advanced heart failure, cardiothoracic surgery, cardiac pathology, immunology, and infectious disease. Education of frontline providers who are most likely to encounter FM first is essential to increase timely access to appropriately resourced facilities, to prevent multiorgan system failure, and to tailor disease-specific therapy as early as possible in the disease process.

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The “TIDE”-Algorithm for the Weaning of Patients With Cardiogenic Shock and Temporarily Mechanical Left Ventricular Support With Impella Devices. A Cardiovascular Physiology-Based Approach

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.563484 ◽

2021 ◽

Vol 8 ◽

Author(s):

Carsten Tschöpe ◽

Frank Spillmann ◽

Evgenij Potapov ◽

Alessandro Faragli ◽

Konstantinos Rapis ◽

...

Keyword(s):

Cardiogenic Shock ◽

Life Support ◽

Extracorporeal Life Support ◽

Left Ventricular ◽

Fulminant Myocarditis ◽

Circulatory Support ◽

Heart Catheterization ◽

Cardiovascular Physiology ◽

Weaning Failure ◽

Ventricular Support

Objectives: Mechanical circulatory support (MCS) is often required to stabilize therapy-refractory cardiogenic shock patients. Left ventricular (LV) unloading by mechanical ventricular support (MVS) via percutaneous devices, such as with Impella® axial pumps, alone or in combination with extracorporeal life support (ECLS, ECMELLA approach), has emerged as a potential clinical breakthrough in the field. While the weaning from MCS is essentially based on the evaluation of circulatory stability of patients, weaning from MVS holds a higher complexity, being dependent on bi-ventricular function and its adaption to load. As a result of this, weaning from MVS is mostly performed in the absence of established algorithms. MVS via Impella is applied in several cardiogenic shock etiologies, such as acute myocardial infarction (support over days) or acute fulminant myocarditis (prolonged support over weeks, PROPELLA). The time point of weaning from Impella in these cohorts of patients remains unclear. We here propose a novel cardiovascular physiology-based weaning algorithm for MVS.Methods: The proposed algorithm is based on the experience gathered at our center undergoing an Impella weaning between 2017 and 2020. Before undertaking a weaning process, patients must had been ECMO-free, afebrile, and euvolemic, with hemodynamic stability guaranteed in the absence of any inotropic support. The algorithm consists of 4 steps according to the acronym TIDE: (i) Transthoracic echocardiography under full Impella-unloading; (ii) Impella rate reduction in single 8–24 h-steps according to patients hemodynamics (blood pressure, heart rate, and ScVO2), including a daily echocardiographic assessment at minimal flow (P2); (iii) Dobutamine stress-echocardiography; (iv) Right heart catheterization at rest and during Exercise-testing via handgrip. We here present clinical and hemodynamic data (including LV conductance data) from paradigmatic weaning protocols of awake patients admitted to our intensive care unit with cardiogenic shock. We discuss the clinical consequences of the TIDE algorithm, leading to either a bridge-to-recovery, or to a bridge-to-permanent LV assist device (LVAD) and/or transplantation. With this protocol we were able to wean 74.2% of the investigated patients successfully. 25.8% showed a permanent weaning failure and became LVAD candidates.Conclusions: The proposed novel cardiovascular physiology-based weaning algorithm is based on the characterization of the extent and sustainment of LV unloading reached during hospitalization in patients with cardiogenic shock undergoing MVS with Impella in our center. Prospective studies are needed to validate the algorithm.

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Extracorporeal life support survival in a pediatric hematopoietic cellular transplant recipient with presumed GvHD-related fulminant myocarditis

Bone Marrow Transplantation ◽

10.1038/bmt.2017.114 ◽

2017 ◽

Vol 52 (9) ◽

pp. 1330-1333 ◽

Cited By ~ 1

Author(s):

M S Zinter ◽

B D Barrows ◽

P C Ursell ◽

K Kowalek ◽

K Kalantar ◽

...

Keyword(s):

Transplant Recipient ◽

Life Support ◽

Extracorporeal Life Support ◽

Fulminant Myocarditis

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Critical Concepts in Extracorporeal Life Support for Cardiogenic Shock

Cardiothoracic Critical Care ◽

10.1093/med/9780190082482.003.0024 ◽

2020 ◽

pp. 231-240

Author(s):

Juan C. Diaz Soto ◽

Justin A. Fried ◽

A. Reshad Garan

Keyword(s):

Cardiogenic Shock ◽

Life Support ◽

Extracorporeal Life Support ◽

Aortic Insufficiency ◽

Fulminant Myocarditis ◽

Circulatory Support ◽

Cardiac Transplant ◽

Ventricular Assist ◽

Primary Graft Failure ◽

Va Ecmo

This chapter examines venoarterial extracorporeal membrane oxygenation (VA-ECMO), also known as extracorporeal life support, which is increasingly used to support patients with refractory cardiogenic shock and cardiopulmonary collapse. VA-ECMO is a simplified form of cardiopulmonary bypass which provides both circulatory support and gas exchange. The underlying etiology of the cardiogenic shock is critical to determine the optimal use of this therapy and prognosis. Primary ischemic etiologies such as acute myocardial infarction and non-ischemic etiologies such as fulminant myocarditis, peripartum cardiomyopathy, decompensated pulmonary hypertension, and primary graft failure following cardiac transplant causing cardiogenic shock are frequent indications for VA-ECMO and represent a heterogenous postoperative patient population. However, despite VA-ECMO's broad applicability, a number of contraindications exist: severe, irreversible, non-cardiac organ failure limiting survival; irreversible cardiac failure if transplantation or long-term ventricular assist device will not be considered; severe aortic insufficiency; and aortic dissection. Understanding the potential complications and the hemodynamic consequences of VA-ECMO support is critical to recognize and mitigate some of the risks associated with this therapy and to avoid some common pitfalls with its use. The chapter then looks at the management of patients on VA-ECMO.

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