CC Cardiol Croat Cardiologia Croatica Cardiol. Croat. 1848-543X 1848-5448 Croatian Cardiac Society CC 2024 19_11-12_553-4 10.15836/ccar2024.553 Extended Abstract Acute and intensive cardiology Mechanical circulatory support in fulminant myocarditis: a single center experience https://orcid.org/0009-0009-0013-9858GrbićLucija1 https://orcid.org/0000-0002-5631-0353ŠipušDubravka2* https://orcid.org/0000-0003-0497-6871PerčinLuka2 https://orcid.org/0000-0003-2633-3439FabijanovićDora2 https://orcid.org/0000-0002-3197-2190PašalićMarijan2 https://orcid.org/0000-0002-2599-553XJurinHrvoje2 https://orcid.org/0000-0003-0561-6704PlanincIvo2 https://orcid.org/0000-0002-9346-6402SamardžićJure12 https://orcid.org/0000-0002-4772-5549Čikeš VodušekMaja12 https://orcid.org/0000-0001-5979-2346SkorićBoško12 https://orcid.org/0000-0001-9101-1570MiličićDavor12 https://orcid.org/0000-0002-5052-6559LovrićDaniel2 University of Zagreb, School of Medicine, Zagreb, Croatia University Hospital Center Zagreb, Zagreb, Croatia ADDRESS FOR CORRESPONDENCE: Dubravka Šipuš, Klinički bolnički centar Zagreb, Kišpatićeva 12, HR-10000 Zagreb, Croatia. / Phone: +385-91-7344-878 / Email: dubravka.sipus@gmail.com 112024 112024 19 11-12 553 554 13102024 31102024 Croatian Cardiac Society 2024 Croatian Cardiac Society KEYWORDS: myocarditisextracorporeal membrane oxygenation

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.

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 AsthmaGastritis Emphysema GastritisSmoking / Smoking / SclerodermaSmoking HypertensionHypothyroidism AsthmaSmoking
Etiology Influenza B Influenza A ? Influenza B ? SARS-CoV-2 Influenza A S. pyogenes
ECHO, admission:EF (%)TAPSE (mm) 20/ 105 1511 3510 35/ 1526 3518 4012
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/minLevosimendan Dobutamine 10.26 mcg/kg/minNorepinephrine 0.31 mcg/kg/min Dobutamine (unknown dose) Dobutamine 4.48 mcg/kg/minMilrinone 0.5 mcg/kg/min Dobutamine 16.6 mcg/kg/min, Norepinephrine 0.33 mcg/kg/min Dobutamine 9.72 mcg/kg/minMilrinone 0.5 mcg/kg/min Dobutamine 11.1 mcg/kg/minNorepinephrine 0.4 mcg/kg/minArgipressinAngiotensin II 20 ng/kg/min Dobutamine 9 mcg/kg/min, Norepinephrine 0.11 mcg/kg/minArgipressinAngiotensin II 40 ng/kg/min
MCS VA ECMOImpella VAV ECMO VAV ECMOImpella VA ECMOProtekSolo VA ECMOProtekSoloImpella Impella VAV ECMOImpella 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 MethylprednisoloneHydrocortisone MethylprednisoloneHydrocortisone Methylprednisolone MethylprednisoloneHydrocortisone Methylprednisolone MethylprednisoloneHydrocortisone MethylprednisoloneHydrocortisone
Immunoglobulins Yes Yes Yes Yes Yes Yes Yes Yes
Complications Death SepsisGI BleedingLimb ischemia Harlequin syndrome Sepsis Sepsis / Impella thrombosis Limb ischemia
ECHO, discharge:EF (%)TAPSE (mm) 50 5013 4018 5820 155 6326 4518 5012
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

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 HangWChenCSeubertJMWangDW. Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes. Signal Transduct Target Ther. 2020 December 11;5(1):287. 10.1038/s41392-020-00360-y33303763 ModyKPTakayamaHLandesEYuzefpolskayaMColomboPCNakaY Acute mechanical circulatory support for fulminant myocarditis complicated by cardiogenic shock. J Cardiovasc Transl Res. 2014 March;7(2):156–64. 10.1007/s12265-013-9521-924420915