Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock due to myocarditis in adult patients

Abstract

Myocarditis is an inflammatory disease of the heart muscle with established histological, immunological and immunohistochemical diagnostic criteria. Different triggers could be advocated as possible etiologies of myocarditis such as viral and non-viral infections, medications, systemic autoimmune diseases and toxic reactions. The spectrum of clinical presentations of myocarditis is broad and varies from subclinical asymptomatic courses to refractory cardiogenic shock. The prognosis of patients with myocarditis depends mainly on the severity of clinical presentation. In particular, myocarditis patients developing cardiogenic shock refractory to optimal maximal medical treatment may benefit from the use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a temporary mechanical circulatory support (MCS).The aim of the present report is to offer a review of the most important articles of the literature showing the results of VA-ECMO in the specific setting of cardiogenic shock due to myocarditis in adult patients. J Thorac Dis 2016;8(7):E495-E502 jtd.amegroups.com characterized by tissue hypoperfusion and multiorgan failure requiring prompt interventions. Initially refractory cardiogenic shock is supported with temporary MCS as a "bridge to decision" before considering the patient eligible for a long-term device implantation in case of no recovery. This general trend has been regularly highlighted by the Annual Reports of the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) (4,5). The implantation of long-term MCS in cardiogenic shock patients, i.e., INTERMACS Level 1 patients, fell since 2006 from 41% to 14%. As a consequence, there has been a considerable increase from 8% to 30% in the implantation of long-term MCS in INTERMACS Level 3 patients, i.e., stable but inotrope-dependent heart failure patients. In this subgroup of critically ill and unstable patients in cardiogenic shock, VA-ECMO allows, on the one hand, temporary hemodynamic stabilization with improvement of end-organ function and, on the other hand, gives the time to perform complementary diagnostic exams and to decide the therapeutic strategy in these high-risk candidates for immediate long-term MCS implantation (6). VA-ECMO could be implanted and removed directly at the bedside in the intensive care unit and offers a reasonable solution in term of cost-effectiveness.Patients who do not show myocardial recovery during VA-ECMO support could be directed to longterm ventricular assist device implantation or heart transplantation depending on age, general clinical and functional status, life expectancy and organs function (brain, lung, liver and kidneys). Finally, as stated by the European Society of Cardiology guidelines for the diagnosis and treatment of acute and chronic heart failure, short-term MCS should be considered (as a "bridge to recovery") in patients remaining severely hypoperfused despite inotropic therapy and with a potentially reversible cause (e.g., viral myocarditis) or a potentially ...

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