Outcomes With Peripheral Venoarterial Extracorporeal Membrane Oxygenation for Suspected Acute Myocarditis: 10-Year Experience From the Extracorporeal Life Support Organization Registry

Abstract

Background: Acute myocarditis can result in severe hemodynamic compromise requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO). Outcomes and factors associated with mortality among myocarditis patients are not well described in the modern ECMO era. Methods: We queried the Extracorporeal Life Support Organization registry from 2011 to 2020 for adults with suspected acute myocarditis undergoing peripheral VA-ECMO support. The primary outcome was in-hospital mortality and was compared to all-comers receiving VA-ECMO in the registry over the same period. Secondary outcomes were rates of bridging to advanced therapies and ECMO complications. We used multivariable logistic regression to examine factors associated with in-hospital mortality. Results: Among 850 patients with suspected acute myocarditis receiving peripheral VA-ECMO, the mean age was 41 years, 52% were men, 39% Asian race, and 14.8% underwent extracorporeal cardiopulmonary resuscitation. During the study period, in-hospital mortality steadily declined and was 58.3% for all all-comers receiving VA-ECMO compared with 34.9% for patients with myocarditis ( P <0.001). After multivariable modeling, risk factors for mortality were earlier year of support, older age, higher weight, Asian race, need for extracorporeal cardiopulmonary resuscitation, sepsis, and lower mean arterial pressure and pH prior to ECMO initiation. ECMO complications including bleeding, limb ischemia, infections and ischemic stroke were more common among nonsurvivors and significantly declined during the study period. Conclusions: Compared with all-comers supported with VA-ECMO, in-hospital mortality for patients with acute myocarditis is significantly lower, with nearly two-thirds of patients surviving to discharge. Major modifiable risk factors for mortality were ongoing cardiopulmonary resuscitation requiring ECMO and markers of illness severity prior to ECMO.

Contemporary Outcomes of Children With Acute Fulminant Myocarditis Supported With Peripheral Extracorporeal Membrane Oxygenation

“…Given this potential for rapid deterioration, a low threshold for ECMO support, even in patients with conduction abnormalities, with the goals of improving cardiac output and unloading a struggling LV is paramount. This is underscored by a recent analysis by Nunez et al 9 using the Extracorporeal Life Support Organization (ELSO) Registry which demonstrated that increased utilization of peripheral ECMO in adults with AFM and cardiogenic shock from 2011 to 2020 has paralleled a decrease in in-hospital mortality from 44% to 31%. Over the entire study period, mortality was 34.9% for patients with AFM which compared favorably to all comers supported with ECMO where mortality was significantly higher at 58.3% (p < 0.001).…”

“…Over the entire study period, mortality was 34.9% for patients with AFM which compared favorably to all comers supported with ECMO where mortality was significantly higher at 58.3% (p < 0.001). 9 Survival rates for children with myocarditis requiring ECMO have generally been slightly higher than adult cohorts. Although earlier analysis of the ELSO registry noted 61% survival of a cohort from 1995 to 2006, 10 more recent analyses have demonstrated survival of approximately 72% in a cohort from 2007 to 2018.…”

Key Predictors of Outcome in Patients With Fulminant Myocarditis Supported by Venoarterial Extracorporeal Membrane Oxygenation

“…In this issue of Circulation: Heart Failure, Nunez et al 8 discuss outcomes, complications, and factors associated with mortality in 850 patients with suspected FM requiring peripheral VA-ECMO initiation. Data were obtained retrospectively from the Extracorporeal Life Support Organization (ELSO) registry between 2011 and 2020.…”

“…Unmodifiable and modifiable factors identified by the Extracorporeal Life Support Organization (ELSO) registry analysis and other multicenter registries on FM suggest VA-ECMO support strategies must be initiated rapidly. 5,6,8 Outcomes in these patients may be impacted by timely histological diagnosis by endomyocardial biopsy (EMB), immunomodulation, left ventricular (LV) unloading to assist with recovery, and optimal management of anticoagulation to minimize ischemic and bleeding complications.…”

“…Key predictors of outcome in patients with fulminant myocarditis (FM) requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) and factors associated with prognosis.Left, Recognition of high-risk patients with FM as early as possible may prevent the negative spiral of cardiogenic shock and improve outcomes. Unmodifiable and modifiable factors identified by the Extracorporeal Life Support Organization (ELSO) registry analysis and other multicenter registries on FM suggest VA-ECMO support strategies must be initiated rapidly 5,6,8. Outcomes in these patients may be impacted by timely histological diagnosis by endomyocardial biopsy (EMB), immunomodulation, left ventricular (LV) unloading to assist with recovery, and optimal management of anticoagulation to minimize ischemic and bleeding complications.Right, Suggested management of patients with FM who require VA-ECMO support.…”