Concomitant use of veno-arterial extracorporeal membrane oxygenation and Impella in the intensive care unit: a case report of fulminant myocarditis with multi-organ failure

Dear Editor,
We would like to present a case of a young male patient with fulminant myocarditis and multi-organ failure treated in our intensive care unit. In the early phase of the treatment, we simultaneously applied mechanical circulatory support (MCS) devices, including veno-arterial extracorporeal membrane oxygenation (ECMO). The use of short-term MCS devices in fulminant myocarditis and in other forms of severe heart failure has increased in recent years [1]. The results of some clinical trials indicate that this mode of treatment, when applied in the early phase of cardiogenic shock, yields promising final results [2, 3].
A 27-year old, previously healthy man was admitted to the Emergency Department with dyspnea, chest pain, and arterial hypotension. He had been suffering from flu-like syndrome for a week prior to admission. Upon hospital arrival, his mean arterial pressure was 50 mm Hg, and the heart rate was 120 beats per minute. Transthoracic echocardiogram (TTE) revealed severe dysfunction of both ventricles with 15% left ventricular (LV) ejection fraction (EF), 8 cm s-1 velocity-time integral of the left ventricle outflow track (LVOT VTI), and 12 mm tricuspid annular plane systolic excursion (TAPSE). Laboratory tests showed troponin above 10000 ng L-1, CK MB of 75.52 ng L-1, and ProBNP of 16497 ng L-1.
Infusion of norepinephrine with a dose of 0.3 µg kg-1 min-1 was started, and the patient was immediately transferred to the catheterization laboratory (cath lab) where coronarography revealed unaffected coronary arteries. In the cath lab, an intra-aortic balloon pump (IABP) was placed, the augmentation was set at 1 : 1, and a diagnosis of fulminant myocarditis was made. Several hours later the symptoms of cardiogenic shock intensified, so the doses of norepinephrine were escalated, and epinephrine was added.
Further hemodynamic deterioration led to the implementation of peripheral veno-arterial ECMO (Cardiohelp, Maquet, Germany) using fluoroscopy. A 23-Fr multi-stage venous cannula was inserted through the right femoral vein with the tip placed in the right atrium. A 17-Fr single-stage arterial cannula was inserted into the left common femoral artery, and a 6-Fr reperfusion cannula was introduced into the left superficial femoral artery. The flow during ECMO was set at 3.8 L min-1, and the augmentation of IABP was continued at 1 : 1. Immediately after ECMO was commenced in the cath lab, the patient was transferred to our...


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