Acute mechanical circulatory support for fulminant myocarditis complicated by cardiogenic shock

Mechanical Circulatory Support Systems in Fulminant Myocarditis: Recent Advances and Outlook

Background: Fulminant myocarditis (FM) constitutes a severe and life-threatening form of acute cardiac injury associated with cardiogenic shock. The condition is characterised by rapidly progressing myocardial inflammation, leading to significant impairment of cardiac function. Due to the acute and severe nature of the disease, affected patients require urgent medical attention to mitigate adverse outcomes. Besides symptom-oriented treatment in specialised intensive care units (ICUs), the necessity for temporary mechanical cardiac support (MCS) may arise. Numerous patients depend on these treatment methods as a bridge to recovery or heart transplantation, while, in certain situations, permanent MCS systems can also be utilised as a long-term treatment option. Methods: This review consolidates the existing evidence concerning the currently available MCS options. Notably, data on venoarterial extracorporeal membrane oxygenation (VA-ECMO), microaxial flow pump, and ventricular assist device (VAD) implantation are highlighted within the landscape of FM. Results: Indications for the use of MCS, strategies for ventricular unloading, and suggested weaning approaches are assessed and systematically reviewed. Conclusions: Besides general recommendations, emphasis is put on the differences in underlying pathomechanisms in FM. Focusing on specific aetiologies, such as lymphocytic-, giant cell-, eosinophilic-, and COVID-19-associated myocarditis, this review delineates the indications and efficacy of MCS strategies in this context.

Test Bench for Right Ventricular Failure Reversibility: The Hybrid BiVAD Concept

BACKGROUND

When heart transplantation and myocardial recovery are unlikely, patients presenting with biventricular cardiogenic shock initially treated with extracorporeal membrane oxygenation (ECMO) may benefit from a mechanical support upgrade. In this scenario, a micro-invasive approach is proposed: the combination of the double-lumen ProtekDuo cannula (Livanova, London, UK) and the Impella 5.5 (Abiomed, Danvers, MA) trans-aortic pump that translates into a hybrid BiVAD.

METHODS

All consecutive ECMO patients presenting with biventricular cardiogenic shock and ineligibility to heart transplantation from August 2022 were prospectively enrolled. The clinical course, procedural details, and in-hospital events were collected via electronic medical records.

RESULTS

A total of three patients, who were temporarily not eligible for heart transplantation or durable LVAD due to severe acute pneumonia and right ventricular (RV) dysfunction, were implanted with a hybrid BiVAD. This strategy provided high-flow biventricular support while pulmonary function ameliorated. Moreover, by differentially sustaining the systemic and pulmonary circulation, it allowed for a more adequate reassessment of RV function. All the patients were considered eligible for isolated durable LVAD and underwent less invasive LVAD implantation paired with a planned postoperative RVAD. In all cases, RV function gradually recovered and the RVAD was successfully removed.

CONCLUSIONS

The Hybrid BiVAD represents an up-to-date micro-invasive mechanical treatment of acute biventricular failure beyond ECMO. Its rationale relies on more physiological circulation across the lungs, the complete biventricular unloading, and the possibility of including an oxygenator in the circuit. Finally, the independent and differential control of pulmonary and systemic flows allows for more accurate RV function evaluation for isolated durable LVAD eligibility reassessment.

A Clinical Update on Vasoactive Medication in the Management of Cardiogenic Shock

This is a focused review looking at the pharmacological support in cardiogenic shock. There are a plethora of data evaluating vasopressors and inotropes in septic shock, but the data are limited for cardiogenic shock. This review article describes in detail the pathophysiology of cardiogenic shock, the mechanism of action of different vasopressors and inotropes emphasizing their indications and potential side effects. This review article incorporates the currently used specific risk-prediction models in cardiogenic shock as well as integrates data from many trials on the use of vasopressors and inotropes. Lastly, this review seeks to discuss the future direction for vasoactive medications in cardiogenic shock.

Characteristics and Outcomes of Patients with Inflammatory Cardiomyopathies Receiving Mechanical Circulatory Support: An STS-INTERMACS Registry Analysis

BACKGROUND

Durable mechanical circulatory support (MCS) therapy improves survival in patients with advanced heart failure. Knowledge regarding the outcomes experienced by patients with inflammatory cardiomyopathy (CM) who receive durable MCS therapy is limited.

METHODS AND RESULTS

We compared patients with inflammatory CM with patients with idiopathic dilated CM enrolled in the STS-INTERMACS registry. Among 19,012 patients, 329 (1.7%) had inflammatory CM and 5978 had idiopathic dilated CM (31.4%). The patients with inflammatory CM were younger, more likely to be White, and women. These patients experienced more preoperative arrhythmias and higher use of temporary MCS. Patients with inflammatory CM had a higher rate of early adverse events (<3 months after device implant), including bleeding, arrhythmias, non-device-related infections, neurologic dysfunction, and respiratory failure. The rate of late adverse events (≥3 months) was similar in the 2 groups. Patients with inflammatory CM had a similar 1-year (80% vs 84%) and 2-year (72% vs 76%, P = .15) survival. Myocardial recovery resulting in device explant was more common among patients with inflammatory CM (5.5% vs 2.3%, P < .001).

CONCLUSIONS

Patients with inflammatory CM who received durable MCS appear to have a similar survival compared with patients with idiopathic dilated CM despite a higher early adverse event burden. Our findings support the use of durable MCS in an inflammatory CM population.

Pathophysiology of cardiogenic shock

PURPOSE OF REVIEW

We describe the pathophysiology of cardiogenic shock (CS), from the main pathways to the inflammatory mechanisms and the proteomic features.

RECENT FINDINGS

Although the classical pathophysiological pathways underlying CS, namely reduced organ perfusion due to inadequate cardiac output and peripheral vasoconstriction, have been well-established for a long time, the role of macro-and micro-hemodynamics in the magnitude of the disease and its prognosis has been investigated extensively only over the last few years. Moreover, to complete the complex picture of CS pathophysiology, the study of cytokine cascade, inflammation, and proteomic analysis has been addressed recently.

SUMMARY

Understanding the pathophysiology of CS is important to treat it optimally.

Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock

Cardiogenic shock accounts for ~100,000 annual hospital admissions in the United States. Despite improvements in medical management strategies, in-hospital mortality remains unacceptably high. Multiple mechanical circulatory support devices have been developed with the aim to provide hemodynamic support and to improve outcomes in this population. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the most advanced temporary life support system that is unique in that it provides immediate and complete hemodynamic support as well as concomitant gas exchange. In this review, we discuss the fundamental concepts and hemodynamic aspects of VA-ECMO support in patients with cardiogenic shock of various etiologies. In addition, we review the common indications, contraindications and complications associated with VA-ECMO use.

Extracorporeal Cardiopulmonary Resuscitation for Management of Out-of-Hospital Cardiac Arrest in a Patient with Fulminant Myocarditis

A 68-year-old male with a witnessed out-of-hospital cardiac arrest while jogging who was managed with extracorporeal cardiopulmonary resuscitation (ECPR) is presented. The patient was found to be in refractory ventricular fibrillation by emergency medical service personnel and underwent advanced cardiac life support (ACLS) protocol with placement of an automated chest compression device. He was emergently transported to the cardiac catheterization laboratory. Due to refractory ventricular fibrillation, he was placed on venoarterial extracorporeal membranous oxygenation (VA-ECMO). Coronary angiography at that time showed nonobstructive coronary artery disease. Management with VA-ECMO and other supportive measures were continued for 5 days, after which a cardiac magnetic resonance imaging was performed with findings consistent with acute myocarditis. His condition substantially improved, and he was discharged from the hospital with good neurologic and functional status. Fulminant myocarditis is often fatal, but aggressive supportive measures with novel ECPR protocols may result in recovery, as it happened in this case.

Long-term biventricular circulatory support with POLVAD-MEV paracorporeal pulsatile pumps. Single-centre experience

Introduction

Severe heart failure decompensation requires circulatory mechanical support in emergency situations. Polish paracorporeal pulsatile pumps, POLVAD-MEV, are designed for biventricular end-stage heart dysfunction.

Aim

To evaluate long-term POLVAD-MEV therapy by multiple pump exchange in patients on a transplant list.

Material and methods

There were 3 patients in INTERMACS level 1 referred for emergency POLVAD-MED implantation due to acute heart failure deterioration. The paracorporeal pulsatile mechanical support was applied due to severe biventricular dysfunction.

Results

They were supported by paracorporeal biventricular POLVAD-MEV pumps for 438, 473 and 394 days until heart transplantation. During the hospitalisation the pumps required multiple pumps exchanges within 29 ±10 (4–49) day intervals.

Conclusions

POLVAD-MEV paracorporeal pulsatile pumps present a safe option for long-term circulatory support in a selected group of patients. Therapy requires pump exchange but enables survival while awaiting a heart transplant.

Heart Transplantation Under Biventricular Mechanical Circulatory Support for Fulminant Myocarditis After a Bee Sting: A Case Report

Patient: Female, 36-year-old

Final Diagnosis: Cardiogenic shock • myocarditis

Symptoms: Fever

Medication: —

Clinical Procedure: Mechanical circulatory support

Specialty: Surgery

Severe Eosinophilic Myocarditis in the Portion of Left Ventricular Wall Excised to Insert a Left Ventricular Assist Device for Severe Heart Failure

Described herein are 3 adults in whom histologic study of the left ventricular myocardium excised ("LV core") to insert a left ventricular assist device (LVAD) disclosed severe acute myocarditis and the inflammatory cells included numerous eosinophils (eosinophilic myocarditis). Examination of the clinical records disclosed elevated absolute eosinophil counts at the time of insertion of the LVAD and the counts rapidly (<30 days) returned to normal after the operation. Because of the numerous medications that each patient was taking at the time of LVAD insertion, identification of a specific initiating medication as its cause was not possible. Of the 3 patients, 2 had idiopathic-dilated cardiomyopathy and 1 had ischemic cardiomyopathy and each had had heart failure for years. The eosinophilic myocarditis in these 3 patients appears to have been transient and superimposed on the earlier cardiomyopathy.

Successful treatment of fulminant myocarditis in an adult in emergency department: A case report

RATIONALE

Fulminant myocarditis (FM) has poor prognosis and the usual treatment is inotropes and symptomatic support. The initiation of extracorporeal membrane oxygenation (ECMO) and intra-aortic balloon pumping (IABP) in the emergency department (ED) is a rare event.

PATIENT CONCERNS

We report the case of a 45-year-old man with a complaint of 4 days of high fever and dry cough in the emergency department.

DIAGNOSIS

Transthoracic echocardiogram and the medical history showed presumptive diagnosis was fulminant myocarditis with cardiogenic shock.

INTERVENTIONS

The patient's condition deteriorated drastically and ECMO was initiated immediately after admission. He experienced electrical storm twice during ECMO support and was successfully treated with the combination with IABP.

OUTCOMES

ECMO and IABP were continued for 11 and 14 days respectively. The patient was discharged on the 81th day after admission, with all his laboratory tests returned to normal.

LESSONS SUBSECTIONS

The early initiation of ECMO and IABP in the ED is potentially life-saving for suitable patients with FM. It appears promising but has not yet been routinely implemented in underdeveloped and developing countries.

Intraoperative vasoplegic syndrome in patients with fulminant myocarditis on ventricular assist device placement

PURPOSE

Fulminant myocarditis is uncommon, but life-threatening, and some patients need mechanical circulatory support. This study was performed to evaluate how different types of mechanical circulatory support-biventricular assist device (BiVAD) or left ventricular assist device (LVAD) placement-affect intraoperative hemodynamic status.

METHODS

From January 2013 to September 2016, the patients who underwent BiVAD or LVAD placement for fulminant myocarditis were analyzed. The mean arterial pressure (MAP), mean pulmonary arterial pressure, central venous pressure (CVP), vasoactive score, and inotropic score were recorded at five time points: after the induction of anesthesia; at weaning, 30 min after weaning, and 60 min after weaning from cardiopulmonary bypass (CPB); and at the end of surgery. The vasoactive and inotropic scores were calculated as follows: vasoactive score = norepinephrine (µg/kg/min) × 100 + milrinone (µg/kg/min) × 10 + olprinone (µg/kg/min) × 25: inotropic score = dopamine (µg/kg/min) × 1 + dobutamine (µg/kg/min) × 1 + epinephrine (µg/kg/min) × 100.

RESULTS

We enrolled 16 patients of fulminant myocarditis. Ten of them underwent BiVAD placement, and the other underwent LVAD placement. After weaning from CPB, the BiVAD group had a significantly lower MAP but no difference in CVP. The vasoactive score was significantly higher in the BiVAD group at weaning of CPB (p = 0.015), 30 min after weaning (p = 0.004), 60 min after weaning (p = 0.005), and at the end of surgery (p < 0.016).

CONCLUSION

Patients with BiVAD placement required more vasoactive support to maintain optimal hemodynamic status compared with those with LVAD placement. This result indicates that BiVAD placement was more associated with vasoplegic syndrome.

Identification of Hypotensive Emergency Department Patients with Cardiogenic Etiologies

OBJECTIVE

Identify predictors of cardiogenic etiology among emergency department (ED) patients with hypotension, and use these predictors to create a clinical tool to discern cardiogenic etiology of hypotension.

METHODS

This secondary analysis evaluated a prospective cohort of consecutive patients with hypotension in an urban, academic, tertiary care ED from November 2012 to September 2013. We included adults with hypotension, defined as a new vasopressor requirement, systolic blood pressure (SBP) < 90 mm Hg after at least 1 L of crystalloid or 2 units packed red blood cells, or SBP < 90 mm Hg and fluids withheld due to concern for fluid overload. The primary outcome was cardiogenic etiology, adjudicated by two physician chart review, with 25% paired chart review (kappa = 0.92). We used multivariable logistic regression to predict cardiogenic etiology, utilizing clinical data abstracted from the electronic medical record. We created a prediction score from significant covariates and calculated its test characteristics for cardiogenic hypotension.

RESULTS

Of 700 patients with hypotension, 107 (15.3%, 95% CI: 12.6%-18.0%) had cardiogenic etiology. Independent predictors of cardiogenic etiology were shortness of breath (OR 4.1, 95% CI: 2.5-6.7), troponin > 0.1 ng/mL (37.5, 7.1-198.2), electrocardiographic ischemia (8.9, 4.0-19.8), history of heart failure (2.0, 1.1-3.3), and absence of fever (4.5, 2.3-8.7) (area under the curve [AUC] = 0.83). The prediction score created from these predictors yielded 78% sensitivity and 77% specificity for cardiogenic etiology (AUC = 0.827).

CONCLUSIONS

Clinical predictors offer reasonable ED screening sensitivity for cardiogenic hypotension, while demonstrating sufficient specificity to facilitate early cardiac interventions.

Early characteristics of fulminant myocarditis vs non-fulminant myocarditis: A meta-analysis

BACKGROUND

Fulminant myocarditis (FM) is a sub-category myocarditis. Its primary characteristic is a rapidly progressive clinical course that necessitates hemodynamic support. FM can be difficult to predict at the onset of myocarditis. The aim of this meta-analysis was to identify the early characteristics in FM compared to those of non-fulminant myocarditis (NFM).

METHODS

We searched the databases of MEDLINE, EMBASE, CENTRAL, for studies comparing FM with acute NFM from January 1, 2000 to June 1, 2018. The baseline variables were compared in each study. Mean differences (MD) and relative ratios (RR) were calculated.

RESULTS

Seven studies (158 FM patients and 388 NFM patients) were included in the analysis. The FM group had significantly lower systolic blood pressure (SBP), higher creatine kinase (CK), wider QRS duration, lower left ventricular ejection fraction (LVEF), thicker left ventricular posterior wall diameter (LVPWd), higher incidence of ST depression, ventricular tachycardia/ventricular fibrillation (Vt/Vf) and syncope, less incidence of chest pain than the NFM groups. There was no difference in terms of heart rate (HR), c-reactive protein (CRP), fever, dyspnea, white blood cells (WBC), atrioventricular block (AVB), Q waves, ST elevation, interventricular septum diameter (IVSd), or end-diastolic left ventricular diameter (LVEDd) between FM and NFM.

CONCLUSION

We found that the lower SBP, higher CK, wider QRS duration, lower LVEF, thicker LVPWd, higher incidence of ST depression, Vt/Vf and syncope as well as lower incidence of chest pain were early characteristics of FM.

ADAR1p150 Forms a Complex with Dicer to Promote miRNA-222 Activity and Regulate PTEN Expression in CVB3-Induced Viral Myocarditis

Adenosine deaminases acting on RNA (ADAR) are enzymes that regulate RNA metabolism through post-transcriptional mechanisms. ADAR1 is involved in a variety of pathological conditions including inflammation, cancer, and the host defense against viral infections. However, the role of ADAR1p150 in vascular disease remains unclear. In this study, we examined the expression of ADAR1p150 and its role in viral myocarditis (VMC) in a mouse model. VMC mouse cardiomyocytes showed significantly higher expression of ADAR1p150 compared to the control samples. Coimmunoprecipitation verified that ADAR1p150 forms a complex with Dicer in VMC. miRNA-222, which is involved in many cardiac diseases, is highly expressed in cardiomyocytes in VMC. In addition, the expression of miRNA-222 was promoted by ADAR1p150/Dicer. Among the target genes of miRNA-222, the expression of phosphatase-and-tensin (PTEN) protein was significantly reduced in VMC. By using a bioinformatics tool, we found a potential binding site of miRNA-222 on the PTEN gene’s 3′-UTR, suggesting that miRNA-222 might play a regulatory role. In cultured cells, miR-222 suppressed PTEN expression. Our findings suggest that ADAR1p150 plays a key role in complexing with Dicer and promoting the expression of miRNA-222, the latter of which suppresses the expression of the target gene PTEN during VMC. Our work reveals a previously unknown role of ADAR1p150 in gene expression in VMC.

Melatonin Ameliorates Coxsackievirus B3-Induced Myocarditis by Regulating Apoptosis and Autophagy

Current therapeutics options for viral myocarditis are unsatisfactory. Melatonin (MLT), a hormone secreted by the pineal gland and other organs, has protective effects on ischemic heart injury. However, the potential therapeutic effect of MLT on viral myocarditis is unknown. In this study, we investigated the protective effect of MLT on viral myocarditis in a mouse model of myocarditis infected with coxsackievirus B3 (CVB3) and explored the probable mechanisms. Mice with CVB3-induced myocarditis displayed inflammatory cell infiltration and interstitial edema. MLT treatment significantly ameliorated the myocardial injuries. In addition, the rate of autophagy changed, although apoptosis was inhibited in mouse hearts following treatment with MLT. These results suggest that MLT has a strong therapeutic effect on acute viral myocarditis, which is associated with changes in autophagy and apoptosis in the heart. Thus, MLT could be a promising novel therapeutic approach against viral myocarditis.

The Impella Microaxial Flow Catheter Is Safe and Effective for Treatment of Myocarditis Complicated by Cardiogenic Shock: An Analysis From the Global cVAD Registry

BACKGROUND

Myocarditis complicated by cardiogenic shock remains a complex problem. The use of acute mechanical circulatory support devices for cardiogenic shock is growing. We explored the utility of Impella transvalvular microaxial flow catheters in the setting of myocarditis with cardiogenic shock.

METHODS AND RESULTS

We retrospectively analyzed data from 21 sites within the cVAD registry, an ongoing multicenter voluntary registry at sites in North America and Europe that have used Impella in patients with myocarditis. Myocarditis was defined by endomyocardial biopsy (n = 11) or by clinical history without angiographic evidence of coronary disease (n = 23). A total of 34 patients received an Impella 2.5, CP, 5.0, or RP device for cardiogenic shock complicating myocarditis. Baseline characteristics included age 42 ± 17 years, left ventricular ejection fraction (LVEF) 18% ± 10%, cardiac index 1.82 ± 0.46 L·min^-1·m^-2, pulmonary capillary wedge pressure 25 ± 7 mm Hg, and lactate 27 ± 31 mg/dL. Before Impella placement, 32% (n = 11) of patients required intra-aortic balloon pump. Mean duration of Impella support was 91 ± 74 hours; 21 of 34 patients (62%) survived the index hospitalization and were discharged with an improved mean LVEF of 37.32% ± 20.31% (P = .001); 15 patients recovered with successful support, 5 patients were transferred to another hospital on initial Impella support, 1 patient underwent orthotopic heart transplantation. Ten patients required transition to another mechanical circulatory support device.

CONCLUSIONS

This is the largest analysis of Impella-supported myocarditis cases to date. The use of Impella appears to be safe and effective in the settings of myocarditis complicated by cardiogenic shock.

Insufficient left ventricular unloading after extracorporeal membrane oxygenation : A case-series observational study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is a method widely used to support circulation in patients with fulminant myocarditis (FM). However, a common complication associated with ECMO is left ventricular (LV) overload.

METHODS

This case series observed the effects of intra-aortic balloon pump (IABP) and beta-blockers for the treatment of LV overload after ECMO. The cases of eight patients with FM who underwent ECMO from September 2009 to July 2016 were reviewed.

RESULTS

Six of the eight patients survived. After ECMO treatment, insufficient LV unloading occurred in six patients. Among these six patients, three experienced electrical storm but spontaneous circulation returned after interventions with beta-blockers and IABP. The survivors demonstrated full recovery of cardiac function.

CONCLUSION

Beta-blockers may prevent the occurrence of electrical storm, and IABP is feasible for the treatment of LV overload after ECMO application.

Diagnosis, medical treatment, and stepwise mechanical circulatory support for fulminat myocarditis

Fulminant myocarditis is one of the most challenging diseases. We sought to examine the outcomes of our multidisciplinary treatment strategy for fulminant myocarditis. A retrospective review of consecutive 30 patients with fulminant myocarditis was conducted. Of the 30 patients, 25 required mechanical circulatory support (MCS). Percutaneous extracorporeal membrane oxygenation (ECMO) was the first-line therapy to rescue the patients and inserted in 23 of them. The other 2 were implanted with temporary ventricular assist device (t-VAD) with extracorporeal centrifugal pump(s). Sixteen of the ECMO-supported patients were later transitioned to t-VAD. Of the 18 patients who underwent t-VAD support, heart function recovered and the VAD was explanted in 10. Four patients were bridged to long-term VAD and the other 4 died on t-VAD. Two patients were directly bridged to long-term VAD by ECMO. Heart function recovered only with ECMO in 4 patients and 1 died on ECMO. Overall survival rate was 83.3%. The duration of ECMO support significantly correlated with total bilirubin level, which was a significant risk factor for mortality. Pathologically, 7 patients (23.3%) had eosinophilic myocarditis and 1 (3.3%) had giant-cell myocarditis, and all the 8 patients underwent immunosuppressive therapy including steroids. Heart function recovered to normal level in 7 of them (87.5%). Timely conversion from the percutaneous ECMO to the temporary VAD before elevation of total bilirubin level is crucial for improving the clinical outcomes. Endomyocardial biopsy is needed to be done as soon as possible, because immunosuppressive therapy carries promising outcomes in certain etiologies.

Early Prediction Model for Successful Bridge to Recovery in Patients With Fulminant Myocarditis Supported With Percutaneous Venoarterial Extracorporeal Membrane Oxygenation - Insights From the CHANGE PUMP Study

BACKGROUND

Cardiac recovery and prevention of end-organ damage are the cornerstones of establishing successful bridge to recovery (BTR) in patients with fulminant myocarditis (FM) supported with percutaneous venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, the timing and method of successful BTR prediction still remain unclear. We aimed to develop a prediction model for successful BTR in patients with FM supported with percutaneous VA-ECMO.Methods and Results:This was a retrospective multicenter chart review enrolling 99 patients (52±16 years; female, 42%) with FM treated with percutaneous VA-ECMO. The S-group comprised patients who experienced percutaneous VA-ECMO decannulation and subsequent discharge (n=46), and the F-group comprised patients who either died in hospital or required conversion to other forms of mechanical circulatory support (n=53). At VA-ECMO initiation (0-h), the S-group had significantly higher left ventricular ejection fraction (LVEF) and lower aspartate aminotransferase (AST) concentration than the F-group. At 48 h, the LVEF, increase in the LVEF, and reduction of AST from 0-h were identified as independent predictors in the S-group. Finally, we developed an S-group prediction model comprising these 3 variables (area under the curve, 0.844; 95% confidence interval, 0.745-0.944).

CONCLUSIONS

We developed a model for use 48 h after VA-ECMO initiation to predict successful BTR in patients with FM.

Inflammatory Cardiomyopathic Syndromes

Inflammatory activation occurs in nearly all forms of myocardial injury. In contrast, inflammatory cardiomyopathies refer to a diverse group of disorders in which inflammation of the heart (or myocarditis) is the proximate cause of myocardial dysfunction, causing injury that can range from a fully recoverable syndrome to one that leads to chronic remodeling and dilated cardiomyopathy. The most common cause of inflammatory cardiomyopathies in developed countries is lymphocytic myocarditis most commonly caused by a viral pathogenesis. In Latin America, cardiomyopathy caused by Chagas disease is endemic. The true incidence of myocarditis is unknown to the limited utilization and the poor sensitivity of endomyocardial biopsies (especially for patchy diseases such as lymphocytic myocarditis and sarcoidosis) using the gold-standard Dallas criteria. Emerging immunohistochemistry criteria and molecular diagnostic techniques are being developed that will improve diagnostic yield, provide additional clues into the pathophysiology, and offer an application of precision medicine to these important syndromes. Immunosuppression is recommended for patients with cardiac sarcoidosis, giant cell myocarditis, and myocarditis associated with connective tissue disorders and may be beneficial in chronic viral myocarditis once virus is cleared. Further trials of immunosuppression, antiviral, and immunomodulating therapies are needed. Together, with new molecular-based diagnostics and therapies tailored to specific pathogeneses, the outcome of patients with these disorders may improve.

Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association

Cardiogenic shock is a high-acuity, potentially complex, and hemodynamically diverse state of end-organ hypoperfusion that is frequently associated with multisystem organ failure. Despite improving survival in recent years, patient morbidity and mortality remain high, and there are few evidence-based therapeutic interventions known to clearly improve patient outcomes. This scientific statement on cardiogenic shock summarizes the epidemiology, pathophysiology, causes, and outcomes of cardiogenic shock; reviews contemporary best medical, surgical, mechanical circulatory support, and palliative care practices; advocates for the development of regionalized systems of care; and outlines future research priorities.

Duration of veno-arterial extracorporeal life support (VA ECMO) and outcome: an analysis of the Extracorporeal Life Support Organization (ELSO) registry

Background

Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is an effective rescue therapy for severe cardiorespiratory failure, but morbidity and mortality are high. We hypothesised that survival decreases with longer VA ECMO treatment. We examined the Extracorporeal Life Support Organization (ELSO) registry for a relationship between VA ECMO duration and in-hospital mortality, and covariates including indication for support.

Methods

All VA runs from the ELSO database from 2002 to 2012 were extracted. Multiple runs and non-VA runs were excluded. Runs were categorized into diagnostic groups. Logistic regression for analysis of the effect of duration on outcome, and multivariate regression for diagnosis and other baseline factors were performed. Non-linear models including piecewise logistic models were fitted.

Results

There were 2699 runs analysed over 14,747 days. Logistic regression analysis of the effect of duration on outcome, and multivariate regression analysis of diagnosis and other baseline factors were performed. In-hospital survival was 41.4% (95% CI 39.6–43.3). 75% of patients were supported for less than 1 week and 96% for less than 3 weeks. Median duration (4 days IQR 2.0–6.8) was greater in survivors (4.1 (IQR 2.5–6.7) vs 3.8 (IQR 1.7–7.0) p = 0.002). The final multivariate model demonstrated increasing survival to day 4 (OR 1.53 (95% CI 1.37–1.71) p < 0.001), decreasing from day 4 to 12 (OR 0.86 (95% CI 0.81–0.91), p < 0.001) with no significant change thereafter (OR 0.98 (95% CI 0.94–1.02), p = 0.400).

Conclusions

ECMO for 4 days or less is associated with higher mortality, likely reflecting early treatment failure. Survival is highest when patients are weaned on the fourth day of ECMO but likely decreases into the second week. While this does not suggest weaning at this point will produce better outcomes, it does reflect the likely time course of ECMO as a bridge in severe shock. Patients with some underlying conditions (like myocarditis and heart transplantation) achieve better outcomes despite longer support duration. These findings merit prospective study for the development of prognostic models and weaning strategies.

Factors and values at admission that predict a fulminant course of acute myocarditis: data from Tokyo CCU network database

Prognosis of acute myocarditis is generally benign, but fulminant cases exist which require advanced life support devices, such as percutaneous cardio-pulmonary support (PCPS) and ventricular assist devices (VAD), and lead to fatal outcomes. The purpose of this study was to identify predictors and their values at admission which might foreshadow a fulminant course of myocarditis. Data from 138 patients (mean age 42.0 years, 79 males) with a diagnosis of acute myocarditis in the Tokyo CCU Network database from 2007 to 2009 were analyzed retrospectively. Patients were divided into fulminant (in-hospital death, or PCPS or VAD requirement, N = 42) and non-fulminant groups (N = 96). Clinical data at admission were compared between them. Overall in-hospital mortality was 14.5%. On multivariate analysis, low systolic blood pressure (BPsys, odds ratio (OR)/mmHg 0.97; 95% confidence interval (CI) 0.93-1.00, p = 0.032) and electrocardiographic QRS complex prolongation (OR/10 ms 1.28; 95% CI 1.10-1.59, p = 0.0034) at admission were independent factors associated with a fulminant course. By receiver operator characteristic curve analysis, the area under the curve predicting a fulminant course was 0.769 for low BPsys and 0.821 for prolongation of QRS duration. The optimal cut-off value was 101 mmHg for BPsys (sensitivity 79.5%, specificity 68.0%), and 120 ms for QRS duration (sensitivity 72.2%, specificity 88.0%). Systolic hypotension and prolonged QRS on admission are predictors of a fulminant course of myocarditis.

Heart Failure and Mortality of Adult Survivors from Acute Myocarditis Requiring Intensive Care Treatment - A Nationwide Cohort Study

Background The correlation between severity and long-term outcomes of pediatric myocarditis have been reported, however this correlation in adults has rarely been studied. Materials and Methods This nationwide population-based cohort study used data from the National Health Insurance Research Database in Taiwan. Patients aged < 75 and > 18 years admitted to an intensive care unit due to acute myocarditis were enrolled and divided into three groups according to mechanical circulatory support (MCS) after excluding major comorbidities. All-cause mortality, cardiovascular death, and heart failure hospitalization were evaluated from January 1, 2001 to December 31, 2011. Results There were 1145 patients with acute myocarditis (mean age 40.2 years, SD: 14.8 years), of which 851 did not require MCS, 99 underwent intra-aortic balloon pump (IABP) support, and 195 extracorporeal membrane oxygenation (ECMO) support. There was no significant difference in heart failure hospitalization between the three groups after index admission. The incidence of cardiovascular death after discharge ranged from 10 % to 22%, which was highest in the ECMO group, and was also significantly different between the three groups within 3 months (p<0.001) but it disappeared after 3 months (p=0.458). The trend was also noted in incidence of all-cause mortality. Conclusions The severity of acute myocarditis did not affect long-term outcomes, however, it was associated with cardiovascular/all-cause death within 3 months after discharge.

Characteristics and Outcomes of Patients With Myocarditis Listed for Heart Transplantation

Background—

Myocarditis can cause dilated cardiomyopathy resulting in end-stage heart failure requiring advanced therapies. There is little contemporary information on the clinical progression, need for mechanical circulatory support, and outcomes of orthotopic heart transplantation of these patients.

Methods and Results—

We queried the UNOS database (United Network for Organ Sharing) for all adults listed for orthotopic heart transplantation (2000–2015) with a listed diagnosis of myocarditis. Comparative and survival analyses were performed. Of 45 941 adults listed for orthotopic heart transplantation during this period, we identified 299 patients (0.7%) with the diagnosis of myocarditis. Compared with patients with nonischemic cardiomyopathy (NICM) and ischemic cardiomyopathy (ICM), myocarditis patients were younger (myocarditis 43.4±14.2 years, NICM 49.8±12.4 years, and ICM 57.5±8.0 years; P <0.001) and more frequently listed as status 1A (myocarditis 44% versus NICM 21% versus ICM 21%; P <0.001), with significantly higher need for mechanical ventilation (myocarditis 11% versus NICM 2% versus ICM 4%; P <0.001), biventricular mechanical circulatory support (myocarditis 19% versus NICM 2%, versus ICM 2%; P <0.001), and extracoroporeal membrane oxygenation (myocarditis 5% versus NICM 0.4% versus ICM 1%; P <0.001). Additionally, patients with myocarditis had higher likelihood of delisting for clinical improvement (hazard ratio, 2.49 [95% confidence interval, 1.63–3.79] versus ICM and hazard ratio, 2.12 [95% confidence interval, 1.40–3.22] versus NICM; P <0.001). Despite higher allosensitization, patients with myocarditis had similar post-transplant rejection, retransplantation, and survival rates compared with other groups.

Conclusions—

Patients with the diagnosis of myocarditis listed for orthotopic heart transplantation are younger, sicker, and recover more frequently but require more biventricular mechanical circulatory support. Heart transplantation survival is comparable to that of patients with other types of heart failure.

An unusual case of fulminant myocarditis closely mimicking ST-segment elevation myocardial infarction and presenting as refractory cardiogenic shock complicated by multiple life-threatening arrhythmias

We report a case of severe fulminant myocarditis that closely mimicked acute inferior ST-segment elevation myocardial infarction (STEMI) and presented with refractory cardiogenic shock, multiple life-threatening arrhythmias and rapidly progressive liver failure. This case was successfully differentiated from STEMI by emergency coronary angiography. Recurrent cardiogenic shock was reversed by intra-aortic balloon pumping (IABP). Life-threatening arrhythmias including ventricular tachycardia, ventricular fibrillation, and high-degree atrioventricular block (AVB) were terminated by immediate cardioversion and temporary pacemaker. High-dose hydrocortisone effectively attenuated the inflammatory injury to the myocardium. The patient recovered and was well at the follow-up visit four months after discharge.

Panax Notoginseng Saponins Ameliorates Coxsackievirus B3-Induced Myocarditis by Activating the Cystathionine-γ-Lyase/Hydrogen Sulfide Pathway

This study is to determine the therapeutic effects of Panax notoginseng saponins (PNSs) on coxsackievirus B3 (CVB3)-induced myocarditis, and whether cystathionine-γ-lyase (CSE)/hydrogen sulfide (H2S) pathway is involved. Mouse model of myocarditis was induced by CVB3 infection, and the mice were subjected to vehicle (saline) or drug treatments (sodium bisulfide (NaHS), propargylglycine (PAG), or PNSs). The results showed that there were inflammatory cell infiltrations, interstitial edemas, and elevated inflammatory cytokines, in CVB3-induced myocarditis. PAG administration increased, whereas NaHS treatment decreased the severity of the myocarditis. PNS treatment dramatically alleviated these myocardial injuries and decreased the viral messenger RNA (mRNA) expression by the enhanced expression of CSE/H2S pathway. Moreover, the therapeutic effects of PNSs on myocarditis were stronger than those of NaHS. Finally, the effect of PNSs on CSE/H2S pathway and cardiac cell protection were verified in cultured cardiac cells. PNSs may be a promising medication for viral myocarditis therapy.

Venoarterial Extracorporeal Membrane Oxygenation for Acute Fulminant Myocarditis in Adult Patients: A 5-Year Multi-Institutional Experience

BACKGROUND

Acute fulminant myocarditis (AFM) may represent a life-threatening event, characterized by rapidly progressive cardiac compromise that ultimately leads to refractory cardiogenic shock or cardiac arrest. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides effective cardiocirculatory support in this circumstance, but few clinical series are available about early and long-term results. Data from a multicenter study group are reported which analyzed subjects affected by AFM and treated with VA-ECMO during a 5-year period.

METHOD

From hospital databases, 57 patients with diagnoses of AFM treated with VA-ECMO in the past 5 years were found and analyzed. Mean age was 37.6 ± 11.8 years; 37 patients were women. At VA-ECMO implantation, cardiogenic shock was present in 38 patients, cardiac arrest in 12, and severe hemodynamic instability in 7. A peripheral approach was used with 47 patients, whereas 10 patients had a central implantation or other access.

RESULTS

Mean VA-ECMO support was 9.9 ± 19 days (range, 2 to 24 days). Cardiac recovery with ECMO weaning was achieved in 43 patients (75.5%), major complications were observed in 40 patients (70.1%), and survival to hospital discharge occurred in 41 patients (71.9%). After hospital discharge (median follow-up, 15 months) there were 2 late deaths. The 5-year actual survival was 65.2% ± 7.9%, with recurrent self-recovering myocarditis observed in 2 patients (at 6 and 12 months from the first AFM event), and 1 heart transplantation.

CONCLUSIONS

Cardiopulmonary support with VA-ECMO provides an invaluable tool in the treatment of AFM, although major complications may characterize the hospital course. Long-term outcome appears favorable with rare episodes of recurrent myocarditis or cardiac-related events.

Pathological Substratum for a Case of Fulminant Myocarditis Treated with Extracorporeal Membrane Oxygenation and Subsequent Heart Transplantation

Fulminant myocarditis has been defined as the clinical manifestation of cardiac inflammation with rapid-onset heart failure and cardiogenic shock. We report on the case of a 23-yr-old woman with pathology-proven fulminant lymphocytic myocarditis presenting shock with elevated cardiac troponin I and ST segments in V1-2, following sustained ventricular tachycardia and a complete atrioventricular block. About 55 min of intensive cardio-pulmonary resuscitation, with extracorporeal membrane oxygenation support, bridged the patient to orthotopic heart transplantation. The explanted heart revealed diffuse lymphocytic infiltration and myocyte necrosis in all four cardiac chamber walls. Aggressive mechanical circulatory support may be an essential bridge for recovery or even transplantation in patients with fulminant myocarditis with shock.

Management of fulminant myocarditis: a diagnosis in search of its etiology but with therapeutic options

Fulminant myocarditis is a clinical syndrome with signs of acute heart failure, cardiogenic shock, or life-threating rhythm disturbances in the context of suspected myocarditis. It is not an etiological diagnosis, but may have different underlying causes and pathogenetic processes - viral, bacterial, toxic, and autoreactive. Clinical management of the disease entity at the acute stage involves hemodynamic monitoring in an intensive care unit or similar setting. Rapid routine work-up is mandatory with serial EKGs, echocardiography, cardiac MRI, heart catheterization with endomyocardial biopsy for histology, immunohistology, and molecular analysis for the underlying infection and pathogenesis. Heart failure therapy is warranted in all cases according to current guidelines. For fulminant autoreactive myocarditis, immunosuppressive treatment is beneficial; for viral myocarditis, IVIg can resolve the inflammation, reduce the viral load, and even eradicate the microbial agent. ECMO, IABP, ventricular assist devices, LifeVest, or ICD implantation can bridge to recovery or to heart transplantation.

Survival on biventricular mechanical support with the Centrimag® as a bridge to decision: a single-center risk stratification

Objective:

Temporary mechanical assist devices are increasingly being used as a lifesaving bridge to decision in patients requiring cardiopulmonary resuscitation. We report our single-center experience with biventricular Centrimag® pumps over a five-year period.

Method:

Data was retrospectively collected in consecutive patients who required biventricular support from 2008 to 2013. Patients who were supported with central cannulation using the Centrimag® system were analyzed. In addition to demographic information, data pertaining to indications, outcomes and mortality were collected.

Results:

The cohort consisted of 48 patients (19 women and 29 men, mean age of 56 years). The median duration of support was 14 days. The median duration to patient expiration while still on the Centrimag® was 12 days. Thirty-day survival was 56% (27/48). Nine patients were explanted to recovery, while fourteen patients were converted to a durable LVAD, two of whom were then transplanted. We stratified patients into two groups. Group I comprised patients who were either explanted to recovery, converted to durable LVAD or transplanted (23/48) and Group II consisted of patients who either died on the Centrimag® or were explanted for withdrawal of care (25/48). Statistical analysis did not reveal any clinically significant differences between the two groups in terms of age, sex, etiology, hemodynamic, co-morbidities or laboratory parameters.

Conclusion:

The biventricular Centrimag® can be used as a bridge to decision in patients with thirty-day survival of >50%. Parameters to predict 30-day survival in this high-risk cohort continue to remain elusive.