Successful bridge to recovery in fulminant myocarditis using a biventricular assist device: a case report

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.

Clinical and Economic Evaluation of Impella Treatment for Fulminant Myocarditis - A Preliminary Retrospective Cohort Study in Japan

BACKGROUND

Fulminant myocarditis (FM) is rare but has an extremely poor prognosis. Impella, a catheter-based heart pump, is a new therapeutic strategy, but reports regarding its health economics are lacking.

METHODS AND RESULTS

This retrospective cohort study compared Impella treatment (Group I) with existing treatments (Group E) using medical data collected from October 2017 to September 2021, with a 1-year analysis period. Cost-effectiveness indices were life-years (LY; effect index) and medical fee amount (cost index). Results were validated using probabilistic sensitivity analysis. The incremental cost-effectiveness ratio (ICER) was calculated using quality-adjusted LY (QALY) and medical costs. Each group included 7 patients, and more than half (57.1%) received combined Impella plus extracorporeal membrane oxygenation. There was no significant difference between Groups I and E in 1-year mortality rates (28.6% vs. 57.1%, respectively) or LY (mean [±SD] 163.1±128.3 vs. 107.8±127.3 days, respectively), but mortality risk was significantly lower in Group I than Group E (95% confidence interval 0.02-0.96; P<0.05). Compared with Group E, Group I had higher total costs (9,270,597±4,121,875 vs. 6,397,466±3,801,364 JPY/year; P=0.20) and higher cost-effectiveness (32,443,987±14,742,966 vs. 92,637,756±98,225,604 JPY/LY; P=0.74), which was confirmed in the sensitivity analysis. ICER probability distribution showed 23.2% and 51.5% reductions below 5 million and 10 million JPY/QALY, respectively.

CONCLUSIONS

Impella treatment is more cost-effective than conventional FM treatments. Large-scale studies are needed to validate the added effects and increasing costs.

Atrial-His bundle pacing in fulminant myocarditis with ventricular arrhythmia: a case report

BACKGROUND

Fulminant myocarditis is a clinical syndrome associated with threatening dysrhythmia which temporary pacemaker can be used for life-saving support. As a method of physiological pacing, His bundle pacing (HBP) maintain better cardiac synchronization than traditional right ventricular (RV) pacing.

CASE PRESENTATION

It's a severe case of fulminant myocarditis in a 41-year-old patient who presented for recurrent arrhythmias with hemodynamic instability. Temporary His bundle pacing combined with optimal medical therapy and extracorporeal membrane oxygenators (ECMO) supported him through his critical period of hospitalization.

CONCLUSIONS

During 1-year follow up, the cardiac function recovery was obvious without any pacing related complications. Echocardiography showed better atrioventricular and intra-ventricular synchronization during HBP in DDD mode. This is the first reported case of temporary His-purkinje conduction system pacing used for severe fulminant myocarditis.

Successful treatment of fulminant myocarditis with intra-aortic balloon pump counterpulsation combined with immunoglobulin and glucocorticoid in a young male adult

Background

Fulminant myocarditis (FM) is a serious non-specific inflammatory disease of the myocardium. FM tends to occur in adolescents and the course of the disease progresses rapidly. It is prone to cardiogenic shock (CGS) and multiple organ failure (MOF) with high mortality. We report a case of FM with CGS and MOF in a young male who was successfully treated with intra-aortic balloon pump counterpulsation (IABP) combined with intravenous immunoglobulin (IVIG) and glucocorticoid (GC).

Case summary

A 21-year-old previously healthy man presented with fever, headache, and chest tightness. He came to the hospital for emergency treatment. The laboratory data showed that the levels of serum cardiac troponin I (cTnI), N-terminal B-type natriuretic peptide (NT-proBNP), myocardial zymogram, and neutrophils increased. Echocardiography showed pericardial effusion and decreased left ventricular systolic function. ECG showed diffuse ST-segment elevation. He was clinically diagnosed with FM and admitted to the intensive care unit for treatment. Within 48 h of admission, the clinical course of the patient deteriorated rapidly, with CGS accompanied by MOF, high atrioventricular block (AVB), and ventricular tachycardia (VT). After using mechanical circulatory support (MCS) therapy with IABP, IVIG, GC, continuous renal replacement therapy (CRRT), and mechanical ventilation complicated with a temporary cardiac pacemaker, he recovered normal cardiac function. He made a full recovery and was discharged home on day 21.

Discussion

For patients with FM, early diagnosis, close monitoring, timely use of MCS devices, and active comprehensive treatment are very important. MCS devices such as IABP can become lifesaving tools for the treatment of FM.

Ventricular Assist Devices and Their Usage as a Bridge to Recovery in Patients With Acute Cardiotoxicity and Cardiomyopathy

Cardiotoxicity can reduce the heart's function temporarily and is most commonly caused by radiation, immune reactions, and certain medications. Using a left ventricular assist device (LVAD) as a bridging therapy while waiting for cardiac recovery has been popular lately in patients who have a reduced ejection fraction after significant cardiac injury. Here we analyze the use of LVAD as a bridging therapy in three cases with chemotherapy-induced cardiotoxicity, acute myocarditis, and postpartum cardiac failure. Although LVADs are infamous for their device-related complications, the ejection fraction can increase up to 50% within days to months of usage without any complications in acute cardiotoxic patients that have no underlying significant risk factors or co-morbidities. Hence LVADs are excellent supportive devices while waiting for cardiac recovery, both in maintaining cardiac function and improving the associated organ failures.

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.

A Rising Hope of an Artificial Heart: Left Ventricular Assisted Device - Outcome, Convenience, and Quality of Life

With the introduction of mechanical circulatory support, mainly continuous-flow left ventricular assisted devices (CF-LVAD), prolonging survival in end-stage heart failure patients can be seen in a new light. We also anticipate its use as a definitive therapy to overcome the limited donor organ resources for cardiac transplant. However, LVADs also have undesirable device-related complications and questionable improvement in the quality of life. In this review, we searched published articles using PubMed and Google Scholar to identify the complications and outcome of post-LVAD patients from 2014 to 2019. The studies we used included all study design types and a wide range of demographic variables focusing on age, sex, choice of LVAD as a bridge to cardiac transplant, or definitive therapy. For patients with New York Heart Association (NYHA) Class III B or IV or heart failure with reduced ejection fraction (HFrEF) with maximal medication therapy, there is a significant increase in mean ejection fraction from 4% to 6%. For patients with drug-induced cardiac toxicity or other causes of cardiac toxicity, with no significant risk factors, the ejection fraction increased to nearly 50% within 10-25 days of LVAD usage. There is also a substantial improvement in the quality of life in this literature review comparing to the pre-LVAD stage, as long as complications are taken into account. Data is limited for making an accurate judgment on the quality of life and functional capacity of LVADs. We found that the use of LVADs is not fully cost-effective, but still less financially burdening than a cardiac transplant. Although data from worldwide is limited and restricted to studies having a range of one to two years of follow-up, we conclude that LVADs are promising in improving cardiac function and the best bridging therapy available for patients waiting on a transplant.