The life-saving role of temporary mechanical circulatory support in fulminant myocarditis
Presenter
Jose Alfredo Salinas-Casanova, MD, Instituto de Cardiologia y Medicina Vascular del Tecnologico de Monterrey, San Pedro Garza García, NL, Mexico
Jose Alfredo Salinas-Casanova, MD1, Juan Alberto Quintanilla Gutierrez, MD2, Vicente Jimenez-Franco, MD1, Daniel Lira-Lozano, MD1, Jorge Joya-Harrison, MD1, Mónica M. Flores-Zertuche, MD1, Christian Juarez-Gavino, MD1, Juan C. Ibarrola-Peña, MD1, Marisol Molina-Avilés, MD1, Arturo Martínez-Ibarra, MD1, Rene D. Gomez-Gutierrez, MD3 and Guillermo Torre-Amione, MD1, (1)Instituto de Cardiologia y Medicina Vascular del Tecnologico de Monterrey, San Pedro Garza García, NL, Mexico, (2)Sociedad de Cardiología Intervencionista de México, Monterrey, NL, Mexico, (3)Departamento de ECMO y Terapias Avanzadas de Insuficiencia Cardiopulmonar del Tecnológico de Monterrey, San Pedro Garza García, NL, Mexico
Learning Objectives:
- Suspect in fulminant myocarditis with the acute development of symptoms in previously healthy individuals
- Learn to assess with an initial bedside echocardiogram the biventricular function and identify pericardial effusion
- Recognize early signs of cardiogenic shock in myocarditis
- Treat fulminant myocarditis aggressively with temporary mechanical circulatory support devices and weaning of inotropic support
- Optimize heart failure medical therapy for a maximal biventricular function recovery
Keywords: Cardiogenic Shock, Heart Failure and Hemodynamic Support
Background
Near 3%–9% of patients with myocarditis present with cardiogenic shock as fulminant myocarditis (FM) within <48 hours of admission. Patients often require inotropes and/or temporary mechanical circulatory support (TMCS), although there are no guidelines or trials to support their routine use.
Methods
A 43-year-old female presented to the ER with loss of consciousness and a seizure episode of <30 seconds. Vital signs upon admission were BP 140/90 mmHg, HR 130 bpm, RR 28 bpm and SpO
2 of 80%. Physical examination revealed rhythmic heart sounds and lung auscultation with diffuse bilateral fine crackles. Laboratory exams showed lactate of 6.9 mmol/L, Hs-TnI 4234 ng/L, and BNP 1773 pg/mL. Bedside cardiac echo with severe global hypokinesia with an LVEF of 15%, CI 0.76 l/min/m
2 and CPO 0.27 W, with moderate pericardial effusion, and no tamponade was noted.
Results
The patient was initially classified into a SCAI stage C, and the shock team opted to manage the patient with inotropes and invasive mechanical ventilation, but within minutes presented cardiopulmonary arrest that reclassified the patient to a SCAI stage E with cardiopulmonary arrest, requiring advanced CPR for 53 minutes, and placing VA-ECMO as circulatory support. Pericardial drainage was performed as a consequence of cardiac tamponade observed in a TEE, but without modifications of the shock status. Therefore, an IABP was placed that improved the LVEF. After hemodynamic stabilization, IVIg was administrated due to a positive result for influenza B. An excellent hemodynamical response was observed, with weaning of inotropes, and removal of the ECMO and the IABP. The patient had an excellent clinical and neurological outcome, HFrEF GDMT was started and up titrated, with improvement of the LVEF. At 4 months follow-up, the patient remained asymptomatic and clinically stable.
Conclusions
This case highlights the use of E-CPR as a modality that improves survival and neurological outcomes in patients with cardiac arrest when compared to CPR, but, most importantly, this case shows how TMCS such as VA-ECMO can effectively improve the hemodynamic status in reversible conditions such as fulminant myocarditis.