Abstract/Description
Background: Fulminant myocarditis (FM) is a rare cause of acute heart failure that can lead to a rapid left ventricular ejection fraction (LVEF) decline within four weeks. With in-hospital mortality up to 18.2%, timely mechanical circulatory support (MCS) is essential to stabilize hemodynamics and bridge to recovery or transplantation.
Case: A 49-year-old Japanese man with hypertension and diabetes presented with two weeks of dyspnea and angina after a flu-like illness. On admission, he developed ventricular fibrillation requiring advanced CPR. Physical exam revealed pulmonary congestion. ECG showed repolarization abnormalities. TTE demonstrated severe biventricular dysfunction (LVEF 9%, RVFAC 9%). Labs showed elevated Troponin T (0.29 ng/ml), lactate (2.3 mmol/L), and low SvO₂ (58%). Coronary angiography was unremarkable. RHC confirmed cardiogenic shock, and inotropes were initiated. The initial IABP failed due to refractory atrial tachycardia, and multiorgan failure prompted urgent Bi-V CentriMag implantation. Endomyocardial biopsy identified a lymphocytic infiltrate. After 10 days, LVEF improved to 20% and MCS was removed. He was discharged after 37 days on GDMT. Cardiac MRI confirmed acute myocarditis, LVEF 30%, and RVEF 44%. He was listed for elective transplant (NYHA III, SHFM 72%). One year later, ergospirometry showed VO₂ 13.4 ml/kg/min and muscle efficiency 23% (normal: 30-50%), revealing skeletal muscle myopathy. After four months of rehabilitation, he improved to NYHA I, with LVEF 58% and RVFAC 54%, and at six years, he remains asymptomatic on GDMT.
Conclusion: FM requires prompt recognition and timely MCS. Multidisciplinary management can transform a bridge to transplant into a bridge to lasting recovery.
Faculty Advisor/Mentor
Johanna Contreras, MD, MSc, FACC, FAHA, FASE, FHFSA
Faculty Advisor/Mentor Email
johanna.contreras@mountsinai.org
Faculty Advisor/Mentor Department
Department of Cardiology, Mount Sinai Hospital, New York, NY, USA.
College/School/Affiliation
Eastern Virginia Medical School (EVMS)
Included in
Mechanical Circulatory Support as a Bridge to Early Recovery of Left Ventricular Function in Fulminant Myocarditis
Background: Fulminant myocarditis (FM) is a rare cause of acute heart failure that can lead to a rapid left ventricular ejection fraction (LVEF) decline within four weeks. With in-hospital mortality up to 18.2%, timely mechanical circulatory support (MCS) is essential to stabilize hemodynamics and bridge to recovery or transplantation.
Case: A 49-year-old Japanese man with hypertension and diabetes presented with two weeks of dyspnea and angina after a flu-like illness. On admission, he developed ventricular fibrillation requiring advanced CPR. Physical exam revealed pulmonary congestion. ECG showed repolarization abnormalities. TTE demonstrated severe biventricular dysfunction (LVEF 9%, RVFAC 9%). Labs showed elevated Troponin T (0.29 ng/ml), lactate (2.3 mmol/L), and low SvO₂ (58%). Coronary angiography was unremarkable. RHC confirmed cardiogenic shock, and inotropes were initiated. The initial IABP failed due to refractory atrial tachycardia, and multiorgan failure prompted urgent Bi-V CentriMag implantation. Endomyocardial biopsy identified a lymphocytic infiltrate. After 10 days, LVEF improved to 20% and MCS was removed. He was discharged after 37 days on GDMT. Cardiac MRI confirmed acute myocarditis, LVEF 30%, and RVEF 44%. He was listed for elective transplant (NYHA III, SHFM 72%). One year later, ergospirometry showed VO₂ 13.4 ml/kg/min and muscle efficiency 23% (normal: 30-50%), revealing skeletal muscle myopathy. After four months of rehabilitation, he improved to NYHA I, with LVEF 58% and RVFAC 54%, and at six years, he remains asymptomatic on GDMT.
Conclusion: FM requires prompt recognition and timely MCS. Multidisciplinary management can transform a bridge to transplant into a bridge to lasting recovery.