Venoarterial extracorporeal membrane oxygenation using magnetic levitation centrifugal pumps for fulminant myocarditis in infants, children and young adults

Background: Fulminant myocarditis (FM) is a potentially lethal disease with a wide spectrum of clinical presentation, thus making the diagnosis hard to depict. In cases where acute circulatory failure occurs venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support is a valid management strategy, especially in the pediatric and adult patients. This study aims to report the results of VA ECMO for FM in our Institution.

Methods: Between April 2009 and January 2021, 17 consecutive patients presenting with FM were supported using VA ECMO. We collected data dividing the population between infants, children and young adults. There were 8 male and 9 female patients, median age of 5.2 years [interquartile range (IQR), 2 months to 32 years] and median body weight of 16 kg (IQR, 3.8-56 kg). FM etiology was viral in 8 patients (47%), bacterial in 1 (6%), 2 giant cellular myocarditis (12%) and in 6 patients (35%) the etiology was unknown. Where it was possible also a cardiac biopsy was performed, usually during ECMO or vent implant. The endpoints of the study are: survival, incidence of ECMO-related complications, weaning rate from ECMO, recovery of cardiac function and the association between rescue ECMO (r-ECMO) and no-weaning/mortality. For the survival analysis we divided the population into three groups: infants (0-2 months; n=5), children (2-6 years; n=5) and young adults (24-40 years; n=7).

Results: After a median duration of 168 hours (IQR, 120-240 hours), 13 patients were weaned from support (weaning rate 76 %), 2 (12%) underwent respectively cardiac transplantation and Bi-Vad Berlin Heart implantation and 2 (12%) died while on ECMO support. Bleeding occurred in 6 (35%) patients, infection in 8 (47%) and 5 (29%), all of them infants, required peritoneal dialysis for acute kidney injury. Overall mortality was 35% (6/17 patients): two patients died during ECMO support due to persistent cardiac failure, arrhythmias and bleeding; three patients died after ECMO weaning (2 due to recurrent ventricular failure and 1 for respiratory complications) and 1 died due to multi-organ failure (MOF) after Bi-VAD implantation. Overall survival at follow-up was 65%, with a statistically significant difference (P=0.05) between age groups: in the infant group was 20% (1/5), in the children group 60% (3/5) and in the adult group 100% (7/7). There was no association between r-ECMO and weaning failure (P=0.55) or hospital mortality (P>0.99). During a median follow-up of 76 months (IQR, 52-99 months), there were no late deaths, 1 patient presented a minor neurological sequela, while cardiac function had fully recovered in all late survivors.

Conclusions: The present experience shows that VA ECMO is an effective bridge to myocardial function recovery in patients with FM, including those with circulatory collapse. The rate of hospital complications is decent when in light of the otherwise fatal course of the disease.