ACUTE FULMINANT MYOCARDITIS-MECHANICAL CIRCULATORY SUPPORT A CHANCE TO RECOVERY. (original) (raw)
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Diagnosis, medical treatment, and stepwise mechanical circulatory support for fulminat myocarditis
Journal of artificial organs : the official journal of the Japanese Society for Artificial Organs, 2017
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 8...
Mechanical circulatory support for fulminant myocarditis
Surgery Today, 2008
Fulminant myocarditis is potentially fatal because it progresses rapidly into cardiogenic shock; thus, immediate and appropriate treatment is essential. Mechanical circulatory support (MCS) is an important part of treatment for fulminant myocarditis. We review our experience of treating fulminant myocarditis with MCS. We used MCS with veno-arterial bypass (VAB) to treat seven patients with fulminant myocarditis. Five of these patients were younger than 18 years old. The mean time from arriving at our institution to the initiation of MCS was 15.9 +/- 22.6 h. MCS was initiated within 18 h in six patients. The mean assist time of MCS was 70.9 +/- 35.0 h and six patients were weaned successfully (weaning rate: 85.7%). The remaining patient required support with VAB for 132 h, and a left ventricular assist device was applied. All seven patients were weaned off MCS and discharged. Since severe and rapid hemodynamic compromise is typical of fulminant myocarditis, an immediate decision must be made about whether to initiate MCS. We attribute the excellent results and favorable long-term prognosis of our patients to the early initiation of MCS.
Fulminant myocarditis in adults and children: bi-ventricular assist device for recovery
European Journal of Cardio-Thoracic Surgery, 2004
Objective: Fulminant myocarditis (FM) is uncommon and may be followed by a rapidly intractable cardiogenic shock. We report five consecutive patients with FM successfully bridged to recovery with a mechanical paracorporel biventricular assist device (BiVAD). Methods: Five patients, four adults and one child (mean age 27C/K6 years, range, 5-36 years) underwent implantation from November 1999 to May 2003, for FM. Prior to implantation, all patients required maximal inotropic support, three of them had an intra-aortic balloon pump, the child had an extra-corporel membrane oxygenation (ECMO) support previously inserted in another institution. Cardiac catheterisation showed a mean CPW of 37C/K1 mmHg, mean CVP 18C/K2 mmHg, and mean CI 1.7C/K0.1 l/min. Echocardiogram showed a severe biventricular hypokinesia, without any ventricular dilatation and a mean LVEF at 12.5%. Two patients were implanted in cardiac arrest under external cardiac resuscitation. All patients underwent BiVAD implantation (MEDOS HIA-VAD). A 72 ml right paracorporel ventricle (a 23 ml in the child) was instituted between the double stage venous canula used during CPB and a pulmonary artery outflow canula. A 80 ml left paracorporel ventricle (a 25 ml in the child) was instituted between a left ventricle apical canula and an aorta outflow canula. Results: There was no death. The mean duration support time was 11C/K6 days (from 7 to 21 days). Two patients experienced transitory deficiency due to a stroke. Four patients showed signs of FM on histological findings. Despite serologic examination and viral genome research on myocardial biopsies, pathogenic agents were not identified. At mean follow-up of 31C/K15 months, all the patients fully recovered with a mean LVEFZ60% and no left ventricular dilatation. Conclusions: In FM with intractable cardiogenic shock, the use of a BiVAD as a bridge to recovery is a life saving approach and should be considered before multi-end organ failure.
Mechanical circulatory support for the treatment of children with acute fulminant myocarditis
Journal of Thoracic and Cardiovascular Surgery, 2001
Background: Viral myocarditis may follow a rapidly progressive and fatal course in children. Mechanical circulatory support may be a life-saving measure by allowing an interval for return of native ventricular function in the majority of these patients or by providing a bridge to transplantation in the remainder. Methods: A retrospective chart review of 15 children with viral myocarditis supported with extracorporeal membrane oxygenation (12 patients) or ventricular assist devices (3 patients) was performed. Results: All patients had histories and clinical findings consistent with acute myocarditis. The median age was 4.6 years (range 1 day–13.6 years) with a median duration of mechanical circulatory support of 140 hours (range 48-400 hours). Myocardial biopsy tissue demonstrated inflammatory infiltrates or necrosis, or both, in 8 (67%) of the 12 patients who had biopsies. Overall survival was 12 (80%) of 15 patients, with 10 (83%) survivors of extracorporeal membrane oxygenation and 2 (67%) survivors of ventricular assist device support. Nine (60%) of the 15 patients were weaned from support, with 7 (78%) survivors; the remaining 6 patients were successfully bridged to transplantation, with 5 (83%) survivors. All survivors not undergoing transplantation are currently alive with normal ventricular function after a median follow-up of 1.1 years (range 0.9-5.3 years). Conclusion: Eighty-percent of the children who required mechanical circulatory support for acute myocarditis survived in this series. Recovery of native ventricular function to allow weaning from support can be anticipated in many of these patients with excellent prospects for eventual recovery of full myocardial function.
Journal of Cardiac Failure, 2011
Background: Acute fulminant myocarditis is a life-threatening disease in children. A limited number of reports suggest that mechanical circulatory support (MCS) may be used to successfully bridge children with acute fulminant myocarditis to recovery or transplantation. We evaluated the effectiveness of MCS in children with myocarditis and identified risk factors associated with adverse outcomes. Methods and Results: Between 2001 and 2009, 16 children were treated for myocarditis at our institution; each child received MCS provided by extracorporeal membrane oxygenation, ventricular assist device(s), or both. Of these patients, 75% (12/16) survived: 7 recovered ventricular function, and 5 underwent successful orthotopic heart transplantation. In patients who were bridged to recovery, mean left ventricular ejection fraction significantly improved from initiation to termination of MCS (20 6 9.3% to 62 6 5%; P 5 .0004). Viral pathogens were detected in 11 patients by polymerase chain reaction, and viral presence was associated with death or need for transplantation (P 5 .011). Upon histologic analysis, absence of viral infection and lack of myocardial inflammation were associated with recovery (P values .011 and .044, respectively). Conclusions: In children with acute fulminant and persistent myocarditis, MCS is a life-saving treatment strategy, particularly in the absence of viral infection. (J Cardiac Fail 2011;17:487e494)
European Journal of Cardio-Thoracic Surgery, 2003
Objective: Fulminant myocarditis (FM) is an uncommon but life-threatening condition for which a mechanical circulatory support (MCS) device can be life-saving. However, device selection, weaning and explantation procedures remain poorly defined. Methods: Four patients were bridged to recovery using the Thoratec w biventricular support device. All four were in a state of cardiogenic shock with rapid deterioration of their clinical status despite increasing doses of inotropes. Three patients required mechanical respiratory support, three were anuric and one was dialyzed. Echocardiography showed a mean ejection fraction of 12^8%. Results: Each Thoratec implantation was performed on cardiopulmonary bypass with a beating heart. Three patients underwent biventricular cannulation. The fourth patient underwent left ventricular and right atrial cannulation. All patients manifested evidence of moderate to severe end organ dysfunction after device implantation. However, by explantation, end organ function had recovered in all patients. After a mean duration of 17^10 days, all the patients showed evidence of myocardial recovery. Recovery was confirmed on echocardiography which showed opening of the aortic valve and contraction of both ventricles. The weaning process was performed in 2-5 days by setting the device in a fixed mode and increasing the rate. Device explantation was uneventful in the four patients. At the 6 months echocardiography follow-up, all had normal systolic function. Conclusion: In patients with FM, biventricular support allows full circulatory support and unloads both ventricles until recovery occurs. In this set of patients, weaning and removal procedures are straightforward. These results suggest an aggressive stance toward implantation of MCS in patients with FM.