A child with influenza A (H1N1)-associated myocarditis rescued by extracorporeal membrane oxygenation

Abstract

A 6-year-old boy had cold-like symptoms and was diagnosed with influenza A at a clinic. Administration of oseltamivir and azithromycin did not improve the symptoms. He was referred to our hospital and was diagnosed with H1N1 pneumonia. The patient required ventilator support. However, hypoxia and hypercapnia were uncontrollable. To oxygenate and reduce the carbon dioxide concentration, veno-venous extracorporeal membrane oxygenation (ECMO) was applied 24 h after admission. We established outflow via the right internal jugular vein and inflow via the right femoral vein. Six hours later, an electrical storm of ventricular fibrillation occurred, probably due to influenza myocarditis. Chest compression was started immediately. Both cardioversion and medication were ineffective in treating the electrical storm. Therefore, we decided to switch the veno-venous ECMO to veno-arterial ECMO to maintain systemic flow. During chest compression, a 6-mm graft was anastomosed to the left common femoral artery, and an outflow tube was connected to the graft. Consequently, veno-arterial ECMO was established via outflow through the left common femoral artery and inflow through both the right jugular vein and right femoral vein. Veno-arterial ECMO terminated the electrical storm, and cardiac output improved. Veno-arterial ECMO was provided for 107 h, and was then replaced by veno-venous ECMO. Forty-three hours later, veno-venous ECMO was discontinued. The patient was successfully weaned from the mechanical ventilator on the 9th day after admission. Unfortunately, spinal infarction appeared as a complication. The patient was discharged from the hospital on the 86th day, and has now returned to primary school.

Extracorporeal membrane oxygenation and swine flu

“…Oda et al [1] reported that a mechanical support device was an effective tool for the management of myocarditis due to swine flu and spinal infarction that appeared as a complication in this case. Indeed, the cardiac manifestation of swine flu is uncommon and very interesting [2].…”

“…Editor, I read the recent publication on the management of swine flu carditis with vein-artery plus vein-vein extracorporeal membrane oxygenation (ECMO) with great interest [1]. Oda et al [1] reported that a mechanical support device was an effective tool for the management of myocarditis due to swine flu and spinal infarction that appeared as a complication in this case.…”

“…Grosek et al [4] noted that cases of ''severe cardiorespiratory failure treated with extracorporeal membrane oxygenation are at risk of hypoxic-ischemic injury and infarction of the brain, intracranial hemorrhage, and seizures.'' For the possible mechanism, Oda et al [1] noted that ''this might be related to the hypotension during the chest compression when the electrical storm occurred.'' If this is the exact mechanism, it should lead to some differences between cases that are using and cases that are not using ECMO.…”

Three cases of electrical storm in fulminant myocarditis treated by extracorporeal membrane oxygenation

“…Very few studies have reported ES in patients with ECMO support, and there is only one reported case of ES occurring during veno-venous (V-V) ECMO support in a child with influenza A-associated myocarditis (19). Here, we report three cases of ES in five FM patients treated by V-A ECMO.…”

“…These cases highlight the need to be aware of inadequate LV unloading and reduced myocardial contractility during the peak phase of myocardial edema. Oda et al (19) reported a case of ES which occurred during V-V ECMO support of a child diagnosed as myocarditis. Interestingly, both cardioversion and medication were ineffective in treating the electrical storm, while a switch from V-V ECMO to V-A ECMO successfully maintained systemic flow, and terminated the ES (19).…”