Mechanical circulatory support in fulminant myocarditis: a single center experience

    Authors

    Keywords

    myocarditis, extracorporeal membrane oxygenation

    DOI

    https://doi.org/10.15836/ccar2024.553

    Full Text

    **Introduction:** Fulminant myocarditis (FM) is a severe and rapidly progressive cardiac inflammatory disease which has historically high mortality rates of >50%. However, recent improvements in treatment options, especially in mechanical circulatory support (MCS), have significantly enhanced survival rates (1, 2). **Patients and Methods:** We retrospectively analyzed data from patients who required MCS for FM from the beginning of 2023 to the present. We used descriptive statistical methods to analyze demographic and epidemiological data, treatment options, laboratory data and outcomes. **Results:** Since the beginning of 2023, eight patients admitted for FM required MCS. 50% were male, median age 40 years (range 18 – 55 years). The cause of FM was Influenza in 4 cases, SARS-CoV-2 in 1 case, S. pyogenes in 1 case, while the etiology remains unknown in 2 cases. Before the initiation of MCS, median lactates were 10.55 mmol/L (range 2 – 13.6 mmol/L) and median mean arterial pressure was 68.5 mmHg (range 45 – 85 mmHg). All patients were on inotropic support with dobutamine (median dose 9.72 mcg/kg/min, range 4.48 – 16.6mcg/kg/min) and two received additional milrinone at a dose of 0.5 mcg/kg/min. Four patients required support with norepinephrine (median dose 0.26 mcg/kg/min, range 0.11 – 0.4 mcg/kg/min) and two required additional support with argipressin and angiotensin II. Upon admission, laboratory findings showed a median NT-proBNP of 18,069 ng/L (range 3,373–25,252 ng/L), median troponin I of 3,929.5 ng/L (range 8.5–>50,000 ng/L), and median CRP of 69.3 mg/L (range 2.60–268.7 mg/L). Three patients were placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) for transport to University Hospital Center Zagreb. In total, 6 patients required VA-ECMO support, of whom 4 needed left ventricular unloading (2 with Impella and 2 with ProtekSolo), and 2 required reconfiguration of the ECMO circuit to VAV ECMO due to poor oxygenation. One patient was solely on Impella CP support, and one patient was solely on VV ECMO support. Median MCS support time was 216 hours (range 98 – 480 hours). All patients were successfully weaned from MCS, although one patient died due to MCS complications. In one case, heart function did not recover, leading to the implantation of long-term MCS. Full patients’ data are shown in **Table 1** and **Figure 1**. ### TABLE 1: Patient characteristics. | | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Gender | Male | Male | Male | Male | Female | Female | Female | Female | | Age (years) | 52 | 52 | 21 | 29 | 18 | 41 | 55 | 38 | | BMI (kg/m2) | 24.3 | 22.5 | 26.5 | 28.8 | 18.4 | 20.3 | 29.4 | 16.6 | | Comorbidities | Asthma Gastritis | Emphysema Gastritis Smoking | / | Smoking | / | Scleroderma Smoking | Hypertension Hypothyroidism | Asthma Smoking | | Etiology | Influenza B | Influenza A | ? | Influenza B | ? | SARS-CoV-2 | Influenza A | S. pyogenes | | ECHO, admission: EF (%) TAPSE (mm) | 20 / | 10 5 | 15 11 | 35 10 | 35 / | 15 26 | 35 18 | 40 12 | | MAP (mmHg) | 80 | 49 | 81 | 85 | 45 | 70 | 67 | 48 | | Lactate (mmol/L) | / | 13.5 | / | 4.6 | 12 | 9.1 | 13.2 | 2 | | Inotropes/ vasopressors | **Dobutamine** 7.84 mcg/kg/min **Levosimendan** | **Dobutamine** 10.26 mcg/kg/min **Norepinephrine** 0.31 mcg/kg/min | **Dobutamine** (unknown dose) | **Dobutamine** 4.48 mcg/kg/min **Milrinone** 0.5 mcg/kg/min | **Dobutamine** 16.6 mcg/kg/min, **Norepinephrine** 0.33 mcg/kg/min | **Dobutamine** 9.72 mcg/kg/min **Milrinone** 0.5 mcg/kg/min | **Dobutamine** 11.1 mcg/kg/min **Norepinephrine** 0.4 mcg/kg/min **Argipressin** **Angiotensin II** 20 ng/kg/min | **Dobutamine** 9 mcg/kg/min, **Norepinephrine** 0.11 mcg/kg/min **Argipressin** **Angiotensin II** 40 ng/kg/min | | MCS | VA ECMO Impella | VAV ECMO | VAV ECMO Impella | VA ECMO ProtekSolo | VA ECMO ProtekSolo Impella | Impella | VAV ECMO Impella | VV ECMO | | MCS duration (h) | 98 | 480 | 135 | 240 | 321 | 192 | 480 | 100 | | Hemodialysis/ filters | / | CVVHDF + Oxiris | Cytosorb | / | CVVHDF Cytosorb+Seraph | / | CVVHDF + Cytosorb | CVVHDF + Oxiris | | Corticosteroids | Methylprednisolone | Methylprednisolone Hydrocortisone | Methylprednisolone Hydrocortisone | Methylprednisolone | Methylprednisolone Hydrocortisone | Methylprednisolone | Methylprednisolone Hydrocortisone | Methylprednisolone Hydrocortisone | | Immunoglobulins | Yes | Yes | Yes | Yes | Yes | Yes | Yes | Yes | | Complications | Death | Sepsis GI Bleeding Limb ischemia | Harlequin syndrome | Sepsis | Sepsis | / | Impella thrombosis | Limb ischemia | | ECHO, discharge: EF (%) TAPSE (mm) | 50 | 50 13 | 40 18 | 58 20 | 15 5 | 63 26 | 45 18 | 50 12 | | Outcome | Death | Discharged | Discharged | Discharged | LVAD implantation | Discharged | Discharged | Discharged | [†] BMI = body mass index; CVVHDF = continuous venovenous hemodiafiltration; ECHO = echocardiography; EF = ejection fraction; LVAD = left ventricular assist device, MAP = mean arterial pressure; MCS = mechanical circulatory support; TAPSE = tricuspid annular plane systolic excursion; VA/VAV/VV ECMO = veno-arterial/veno-arterial-venous/veno-venous extracorporeal membrane oxygenation FIGURE 1. **Laboratory parameters.** NT-PROBNP = N-terminal prohormone of brain natriuretic peptide; CRP = C-reactive protein **Conclusion:** Our data support the finding that MCS should be considered in FM and that MCS can be associated with promising results.

    Literature

    1. Hang W, Chen C, Seubert JM, Wang DW. Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes. Signal Transduct Target Ther. 2020 December 11;5(1):287. https://doi.org/10.1038/s41392-020-00360-y
    2. Mody KP, Takayama H, Landes E, Yuzefpolskaya M, Colombo PC, Naka Y, et al. Acute mechanical circulatory support for fulminant myocarditis complicated by cardiogenic shock. J Cardiovasc Transl Res. 2014 March;7(2):156–64. https://doi.org/10.1007/s12265-013-9521-9
    Cardiologia Croatica
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    Mechanical circulatory support in fulminant myocarditis: a single center experience

    Extended Abstract
    Issue11-12
    Published
    Pages553-554
    PDF via DOIhttps://doi.org/10.15836/ccar2024.553
    myocarditis
    extracorporeal membrane oxygenation

    Authors

    Lucija GrbićORCIDUniversity of Zagreb, Zagreb, Croatia
    Dubravka Šipuš*ORCIDUniversity Hospital Center Zagreb, Zagreb, Croatia
    Luka PerčinORCIDUniversity Hospital Center Zagreb, Zagreb, Croatia
    Dora FabijanovićORCIDUniversity Hospital Center Zagreb, Zagreb, Croatia
    Marijan PašalićORCIDUniversity Hospital Center Zagreb, Zagreb, Croatia
    Hrvoje JurinORCIDUniversity Hospital Center Zagreb, Zagreb, Croatia
    Ivo PlanincORCIDUniversity Hospital Center Zagreb, Zagreb, Croatia
    Jure SamardžićORCIDUniversity of Zagreb, Zagreb, Croatia
    Maja Čikeš VodušekORCIDUniversity of Zagreb, Zagreb, Croatia
    Boško SkorićORCIDUniversity of Zagreb, Zagreb, Croatia
    Davor MiličićORCIDUniversity of Zagreb, Zagreb, Croatia
    Daniel LovrićORCIDUniversity Hospital Center Zagreb, Zagreb, Croatia

    *Correspondence email: dubravka.sipus@gmail.com

    Full Text

    Introduction: Fulminant myocarditis (FM) is a severe and rapidly progressive cardiac inflammatory disease which has historically high mortality rates of >50%. However, recent improvements in treatment options, especially in mechanical circulatory support (MCS), have significantly enhanced survival rates (1, 2).

    Patients and Methods: We retrospectively analyzed data from patients who required MCS for FM from the beginning of 2023 to the present. We used descriptive statistical methods to analyze demographic and epidemiological data, treatment options, laboratory data and outcomes.

    Results: Since the beginning of 2023, eight patients admitted for FM required MCS. 50% were male, median age 40 years (range 18 – 55 years). The cause of FM was Influenza in 4 cases, SARS-CoV-2 in 1 case, S. pyogenes in 1 case, while the etiology remains unknown in 2 cases. Before the initiation of MCS, median lactates were 10.55 mmol/L (range 2 – 13.6 mmol/L) and median mean arterial pressure was 68.5 mmHg (range 45 – 85 mmHg). All patients were on inotropic support with dobutamine (median dose 9.72 mcg/kg/min, range 4.48 – 16.6mcg/kg/min) and two received additional milrinone at a dose of 0.5 mcg/kg/min. Four patients required support with norepinephrine (median dose 0.26 mcg/kg/min, range 0.11 – 0.4 mcg/kg/min) and two required additional support with argipressin and angiotensin II. Upon admission, laboratory findings showed a median NT-proBNP of 18,069 ng/L (range 3,373–25,252 ng/L), median troponin I of 3,929.5 ng/L (range 8.5–>50,000 ng/L), and median CRP of 69.3 mg/L (range 2.60–268.7 mg/L). Three patients were placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) for transport to University Hospital Center Zagreb. In total, 6 patients required VA-ECMO support, of whom 4 needed left ventricular unloading (2 with Impella and 2 with ProtekSolo), and 2 required reconfiguration of the ECMO circuit to VAV ECMO due to poor oxygenation. One patient was solely on Impella CP support, and one patient was solely on VV ECMO support. Median MCS support time was 216 hours (range 98 – 480 hours). All patients were successfully weaned from MCS, although one patient died due to MCS complications. In one case, heart function did not recover, leading to the implantation of long-term MCS. Full patients’ data are shown in Table 1 and Figure 1.

    TABLE 1: Patient characteristics.

    Gender
    1
    Male
    2
    Male
    3
    Male
    4
    Male
    5
    Female
    6
    Female
    7
    Female
    8
    Female
    Age (years)
    1
    52
    2
    52
    3
    21
    4
    29
    5
    18
    6
    41
    7
    55
    8
    38
    BMI (kg/m2)
    1
    24.3
    2
    22.5
    3
    26.5
    4
    28.8
    5
    18.4
    6
    20.3
    7
    29.4
    8
    16.6
    Comorbidities
    1
    Asthma Gastritis
    2
    Emphysema Gastritis Smoking
    3
    /
    4
    Smoking
    5
    /
    6
    Scleroderma Smoking
    7
    Hypertension Hypothyroidism
    8
    Asthma Smoking
    Etiology
    1
    Influenza B
    2
    Influenza A
    3
    ?
    4
    Influenza B
    5
    ?
    6
    SARS-CoV-2
    7
    Influenza A
    8
    S. pyogenes
    ECHO, admission: EF (%) TAPSE (mm)
    1
    20 /
    2
    10 5
    3
    15 11
    4
    35 10
    5
    35 /
    6
    15 26
    7
    35 18
    8
    40 12
    MAP (mmHg)
    1
    80
    2
    49
    3
    81
    4
    85
    5
    45
    6
    70
    7
    67
    8
    48
    Lactate (mmol/L)
    1
    /
    2
    13.5
    3
    /
    4
    4.6
    5
    12
    6
    9.1
    7
    13.2
    8
    2
    Inotropes/ vasopressors
    1
    Dobutamine 7.84 mcg/kg/min Levosimendan
    2
    Dobutamine 10.26 mcg/kg/min Norepinephrine 0.31 mcg/kg/min
    3
    Dobutamine (unknown dose)
    4
    Dobutamine 4.48 mcg/kg/min Milrinone 0.5 mcg/kg/min
    5
    Dobutamine 16.6 mcg/kg/min, Norepinephrine 0.33 mcg/kg/min
    6
    Dobutamine 9.72 mcg/kg/min Milrinone 0.5 mcg/kg/min
    7
    Dobutamine 11.1 mcg/kg/min Norepinephrine 0.4 mcg/kg/min Argipressin Angiotensin II 20 ng/kg/min
    8
    Dobutamine 9 mcg/kg/min, Norepinephrine 0.11 mcg/kg/min Argipressin Angiotensin II 40 ng/kg/min
    MCS
    1
    VA ECMO Impella
    2
    VAV ECMO
    3
    VAV ECMO Impella
    4
    VA ECMO ProtekSolo
    5
    VA ECMO ProtekSolo Impella
    6
    Impella
    7
    VAV ECMO Impella
    8
    VV ECMO
    MCS duration (h)
    1
    98
    2
    480
    3
    135
    4
    240
    5
    321
    6
    192
    7
    480
    8
    100
    Hemodialysis/ filters
    1
    /
    2
    CVVHDF + Oxiris
    3
    Cytosorb
    4
    /
    5
    CVVHDF Cytosorb+Seraph
    6
    /
    7
    CVVHDF + Cytosorb
    8
    CVVHDF + Oxiris
    Corticosteroids
    1
    Methylprednisolone
    2
    Methylprednisolone Hydrocortisone
    3
    Methylprednisolone Hydrocortisone
    4
    Methylprednisolone
    5
    Methylprednisolone Hydrocortisone
    6
    Methylprednisolone
    7
    Methylprednisolone Hydrocortisone
    8
    Methylprednisolone Hydrocortisone
    Immunoglobulins
    1
    Yes
    2
    Yes
    3
    Yes
    4
    Yes
    5
    Yes
    6
    Yes
    7
    Yes
    8
    Yes
    Complications
    1
    Death
    2
    Sepsis GI Bleeding Limb ischemia
    3
    Harlequin syndrome
    4
    Sepsis
    5
    Sepsis
    6
    /
    7
    Impella thrombosis
    8
    Limb ischemia
    ECHO, discharge: EF (%) TAPSE (mm)
    1
    50
    2
    50 13
    3
    40 18
    4
    58 20
    5
    15 5
    6
    63 26
    7
    45 18
    8
    50 12
    Outcome
    1
    Death
    2
    Discharged
    3
    Discharged
    4
    Discharged
    5
    LVAD implantation
    6
    Discharged
    7
    Discharged
    8
    Discharged

    BMI = body mass index; CVVHDF = continuous venovenous hemodiafiltration; ECHO = echocardiography; EF = ejection fraction; LVAD = left ventricular assist device, MAP = mean arterial pressure; MCS = mechanical circulatory support; TAPSE = tricuspid annular plane systolic excursion; VA/VAV/VV ECMO = veno-arterial/veno-arterial-venous/veno-venous extracorporeal membrane oxygenation

    FIGURE 1. Laboratory parameters. NT-PROBNP = N-terminal prohormone of brain natriuretic peptide; CRP = C-reactive protein

    Conclusion: Our data support the finding that MCS should be considered in FM and that MCS can be associated with promising results.

    Literature

    1. 1.
      Hang W, Chen C, Seubert JM, Wang DW. Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes. Signal Transduct Target Ther. 2020 December 11;5(1):287.DOI
    2. 2.
      Mody KP, Takayama H, Landes E, Yuzefpolskaya M, Colombo PC, Naka Y, et al. Acute mechanical circulatory support for fulminant myocarditis complicated by cardiogenic shock. J Cardiovasc Transl Res. 2014 March;7(2):156–64.DOI