From the Guidelines
Extracorporeal membrane oxygenation (ECMO) is a valuable life-saving intervention for patients with severe myocarditis who develop cardiogenic shock or cardiac arrest refractory to conventional management. Venoarterial (VA) ECMO is the preferred configuration for myocarditis patients, as it provides both cardiac and respiratory support 1. ECMO should be initiated early when patients show signs of deterioration despite maximal medical therapy, including inotropes (dobutamine 2-20 mcg/kg/min, milrinone 0.375-0.75 mcg/kg/min) and vasopressors (norepinephrine 0.01-3 mcg/kg/min).
Key Considerations for ECMO Support
- Typical ECMO settings include flow rates of 50-80 ml/kg/min, with adjustment based on end-organ perfusion.
- Anticoagulation with unfractionated heparin (target aPTT 50-70 seconds) is essential to prevent circuit thrombosis.
- ECMO support typically continues for 5-14 days, allowing time for myocardial recovery.
- During ECMO, daily echocardiographic assessment helps evaluate cardiac recovery and guide weaning decisions. ECMO is effective for myocarditis because it temporarily assumes cardiac function while allowing the heart to rest and recover from inflammation, as noted in the 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death 1. This approach is particularly beneficial in fulminant myocarditis, which often has good recovery potential if patients can be supported through the acute phase of illness.
From the Research
ECMO Support for Myocarditis
- ECMO (Extracorporeal Membrane Oxygenation) support is a treatment option for myocarditis, particularly in severe cases where patients require advanced hemodynamic support 2, 3.
- Myocarditis is a potentially fatal condition characterized by inflammation of the heart musculature, causing cardiac dysfunction, and symptoms may range from mild to severe 2.
- The use of ECMO support in myocarditis is often reserved for patients with hemodynamic instability, characterized by an inability to maintain adequate end-organ perfusion, and requires inotropic agents or mechanical circulatory devices to facilitate functional recovery 3.
- Approximately 2% to 9% of patients with myocarditis have hemodynamic instability and require ECMO support, with a mortality rate of approximately 28% at 60 days 3.
Diagnosis and Treatment of Myocarditis
- The diagnosis of myocarditis can be suggested by presenting symptoms, elevated biomarkers such as troponins, electrocardiographic changes of ST segments, and echocardiographic wall motion abnormalities or wall thickening 3.
- Cardiac magnetic resonance imaging or endomyocardial biopsy are required for definitive diagnosis, and treatment depends on acuity, severity, clinical presentation, and etiology 3.
- Immunosuppression, such as corticosteroids, is appropriate for patients with myocarditis characterized by eosinophilic or giant cell myocardial infiltrations or due to systemic autoimmune disorders, but the specific immune cells that should be targeted to improve outcomes in patients with myocarditis remain unclear 3, 4, 5.
Immunomodulating Therapies in Myocarditis
- Immunomodulating therapies, such as intravenous immunoglobulin, have been shown to be effective in treating myocarditis, particularly in patients with specific histology or with an arrhythmic burden 4, 5, 6.
- A tailored immunosuppressive therapy may be considered in myocarditis, depending on the phase of the disease and the type of underlying autoimmune or immune-mediated form 4.
- Ongoing clinical trials are assessing the role of high-dosage methylprednisolone in the context of acute myocarditis complicated by heart failure or fulminant presentation, or the role of anakinra to treat patients with acute myocarditis excluding patients with hemodynamically unstable conditions 5.