Medical Student SHSU-COM Houston, Texas, United States
Disclosure(s):
Sarib M. Sultan: No financial relationships to disclose
Background: Fulminant myocarditis causes acute, reversible myocardial inflammation leading to cardiogenic shock. Unlike ischemic disease, MCS in myocarditis primarily serves as a bridge to recovery. Timely stabilization with VA-ECMO or Impella is crucial due to the high likelihood of full cardiac recovery.
Methods: A comprehensive PubMed and JACC search was conducted for all articles published from 2010 to 2025. Further focused the review into seven studies and 12 case reports which were published from 2014-2024 which were included in the final narrative synthesis. From each study, we extracted the variables listed in Table 2, including patient demographics, diagnostic modality (biopsy or imaging), type of mechanical circulatory support used, complications, and clinical outcomes. No formal risk of bias or quality assessment tool was applied due to the predominance of case reports and small case series, for which standardized tools are limited and inconsistently applicable. These findings were compared against outcomes from ischemic cardiogenic shock to highlight mechanistic and prognostic differences. Studies were included if they reported biopsy- or imaging-confirmed myocarditis treated with mechanical circulatory support and provided clinical outcomes; case reports, case series, and observational studies published in English between 2010 and 2025 were eligible, while reviews, abstracts without patient-level data, non-MCS cases, and studies lacking confirmed myocarditis were excluded.
Outcome: Among studies reporting quantitative recovery, full myocardial recovery (LVEF >50%) occurred in 63–78% of myocarditis patients supported with MCS. Cohorts without explicit EF normalization still showed outcomes consistent with recovery. Schrage et al. reported 35–55% survival depending on device strategy, with mortality decreasing from 65% with ECMO alone to 45% with ECMELLA. Pappalardo et al. reported ~70% survival with ECMELLA, Wang et al. observed 72% survival in a national viral myocarditis cohort, and Nuñez et al. found ~65% survival among myocarditis patients requiring peripheral VA-ECMO in the ELSO registry. Despite absent EF follow-up, these results support high reversibility when early MCS is used.
Case reports documenting full recovery with Impella, VA-ECMO, or ECMELLA were excluded due to single-patient design and lack of standardized follow-up. No study offered long-term outcome data; EF normalization at discharge may not exclude later HFpEF or chronic sequelae.
Early MCS initiation ( < 24 hours) and lower lactate predicted improved survival, recovery, and weaning. Ischemic or chronic HF etiologies showed lower recovery and more LVAD dependence. Device heterogeneity prevented meta-analysis, and no study directly compared ECMO versus Impella; improved outcomes with ECMELLA reflect combined unloading, not a head-to-head comparison.
Conclusion: Mechanical circulatory support in acute myocarditis provides temporary hemodynamic stabilization enabling intrinsic recovery. Early MCS appears to improve survival and weaning, though current evidence is limited and descriptive. Standardized timing, weaning criteria, and integration with immunotherapy remain undefined and require prospective, myocarditis-specific research.
