Abstract
Fulminant myocarditis is a peculiar condition characterized by sudden-onset diffuse myocardial inflammation leading to hemodynamic compromise. We report the case of a 15-year-old male adolescent, without any cardiovascular history, who presented sudden-onset severe biventricular systolo-diastolic dysfunction leading to cardiogenic shock, 2 weeks after an episode of respiratory tract infection. A comprehensive treatment regimen was initiated including heart failure treatment, inotropic and vasoactive support, antibiotics, antiviral treatment, intravenous immunoglobulin, and glucocorticoids, but with poor evolution. Bridge-to-transplantation therapy was taken into consideration for hemodynamic stabilization. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support was initiated, first peripherally, via femoral artery and femoral vein access, but secondary to left ventricle (LV) distension, the patient developed pulmonary edema. To decompress the LV, an echocardiography-guided atrial septostomy was performed, and after 2 days, central cannulation (right atrium – ascending aorta) with another cannula for left atrial venting was done, and the patient remained with open sternum. Five days from the initiation of VA-ECMO the patient underwent an orthotopic heart transplantation by bicaval technique with favorable evolution in the follow-up period. Early initiation of VA-ECMO is a salvage intervention in pediatric patients with fulminant myocarditis, but with multiple possible complications. This paper highlights strategies for the optimization of VA-ECMO.