(229) The Use of IVIg and VA ECMO for Acute Fulminant Myocarditis

Introduction: Acute myocarditis, an inflammatory disease of the cardiac muscle, may be due to infection, toxin, medication, or autoimmune etiologies. The diagnosis is often clinical, as a biopsy may not always be possible. Acute myocarditis typically has a favorable outcome and is often self-resolving with a mortality of less than 20%. However, acute myocarditis can progress to acute fulminant myocarditis (AFM), with a mortality of nearly 50%, with acute heart failure and cardiogenic shock.

Description: The patient is a 49 year old female with a past medical history significant for COPD, type 2 diabetes, and substance abuse presented from prison for chest pain and shortness of breath. EKG demonstrated diffuse ST elevations and bedside ultrasound demonstrated a severely reduced ejection fraction. Left heart catheterization was performed revealing clean coronaries and an Impella was placed for cardiac support. The patient developed worsening hypoxia and sustained wide complex ventricular tachycardia despite amiodarone, lidocaine, and defibrillation. The patient was placed on VA-ECMO for increased circulatory support. There was concern for viral myocarditis as a viral prodrome was reported 2-3 days before arrival and she was started on high dose glucocorticoids. Without significant improvement, the decision was made to start high dose IVIG after which the patient started improving. She was decannulated after 16 days, and eventually discharged to rehab.

Discussion: There are case reports of IVIG for AFM and many using VA-ECMO but very few using both for acute fulminant myocarditis. This case demonstrates the benefit of using both for a patient with significant cardiogenic shock despite being on left ventricular support with Impella and VA-ECMO as well as receiving high dose glucocorticoids. With more studies, there is potential for IVIG becoming standard in the treatment of AFM.