Yashwanth Makkapati, DO: No financial relationships to disclose
Background: Influenza virus has been identified as a common viral pathogen in the development of viral myocarditis. Influenza-related myocarditis requiring mechanical circulatory support is associated with worse outcomes than non-influenza causes . However, there is a lack of large-scale studies to provide specific guidance on management of this condition.
Methods: We present the case of a 45-year-old male with a history of asthma, hypertension, and diabetes mellitus requiring veno-venous (VV) ECMO for acute hypoxemic respiratory failure in the setting of influenza A and ARDS. Prior to cannulation, the patient experienced cardiac arrest. After ROSC was obtained, the patient developed SCAI-D cardiogenic shock, limiting oxygenation attempts, and decision was made to initiate VV ECMO as “time to decision” therapy pending transfer.
Following initiation of VV-ECMO, serial evaluation by transesophageal echocardiogram demonstrated severe biventricular failure, evidenced by estimated cardiac output via left ventricular outflow tract volume-time integral of 2L/min with global left ventricular hypokinesis and TAPSE of 0.5cm. Imaging findings with increasing pressor requirement and persistent lactate elevation were consistent with fulminant influenza myocarditis. Given findings and instability, the decision was made to reconfigure for veno-arterial-venous ECMO. Subsequently, left and right heart catheterization were performed showing elevated left and right sided filling pressures, ejection fraction less than 15%, and narrowing pulse pressures to less than 10 mmHg. Thus, the decision was made to place an Impella device for left ventricular offloading.
Outcome: After aggressive mechanical circulatory support measures, in addition to pressors, inotropes, CRRT, and mechanical ventilation, the patient was able to tolerate decannulation of the arterial limb on ECMO day 4 and complete decannulation with Impella removal on ECMO day 5. Given the recency of this case, it is difficult to assess long-term outcomes, however the patient was able to be liberated from mechanical circulatory and ventilatory support. This outcome provides evidence for early initiation of ECMO in the management of cardiogenic shock secondary to influenza-related myocarditis and illustrates the potential for positive short and long term outcomes.
Conclusion: In this case presentation, we will discuss relevant literature, pertinent imaging and hemodynamic data, and our decision-making to demonstrate the potential of positive outcomes with early ECMO support in influenza-related myocarditis.
