Mechanical circulatory support in refractory cardiogenic shock due to influenza virus-related myocarditis

Abstract

BackgroundIn patients with influenza-related myocarditis complicated by refractory cardiogenic shock (rCS) there is scarce evidence for mechanical circulatory support (MCS). We sought to investigate the impact of MCS using combined veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and micro-axial flow pumps in rCS complicating influenza-related myocarditis.MethodsThis is a prospective and observational analysis from the single center Hannover Cardiac Unloading REgistry (HACURE) from two recent epidemic influenza seasons. We analysed patients with verified influenza virus infection-associated myocarditis complicated by rCS admitted to our ICU on MCS. Subsequently, we performed a propensity score matched analysis to patients with acute myocardial infarction complicated by rCS and non-ischemic cardiomyopathy related rCS.ResultsWe describe a series of seven patients with rCS complicating influenza-related myocarditis (mean age: 56±10 years, 58% males, Influenza A/B n=2/5). No patient had been vaccinated prior to the influenza season. MCS was provided using combined VA-ECMO and Impella. In two patients with out-of-hospital cardiac arrest VA-ECMO had been implanted for extracorporeal-cardiopulmonary resuscitation. All patients died within 18 days after hospital admission. By propensity score-based comparison to patients with myocardial infarction- or non-ischemic cardiomyopathy related rCS with combined MCS, 30-day mortality was significantly higher in influenza-related rCS.ConclusionDespite initial stabilisation with combined MCS in patients with rCS complicating influenza-related myocarditis, the detrimental course of shock could not be stopped and all patients died. Potentially, influenza virus infection critically affects other organs besides the heart leading to irreversible end-organ damage, which MCS cannot compensate and, therefore, resulted in a devastating outcome.

Extracorporeal Cardiopulmonary Resuscitation for Management of Out-of-Hospital Cardiac Arrest in a Patient with Fulminant Myocarditis

“…Prior case series of VA-ECMO in cardiogenic shock caused by myocarditis have shown promising results demonstrating survival to hospital discharge ranging from 54% to 77% [ 11 , 18 ]. However, in a case series of seven patients by Sieweke et al, refractory cardiogenic shock secondary to myocarditis caused by influenza was associated with poor survival despite use of VA-ECMO plus the percutaneous LV ventricular assist device Impella (ABIOMED, Danvers, Massachusetts), which the authors attributed to the multiorgan dysfunction often seen with severe influenza infection [ 19 ].…”

ECMO support for viral induced cardiogenic shock: a bridge too far?

“…In this issue of the European Respiratory Journal, SIEWEKE et al [1] report their experience utilising veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) and LV Impella unloading (so called ECMELLA) in influenza-induced myocarditis and shock. Despite such aggressive life support, all seven patients died, the outcome being significantly worse than propensity matched patients with cardiogenic shock either due to ischaemic heart disease or non-ischaemic cardiomyopathy.…”

“…Furthermore, COVID-19 is not influenza. In times of a COVID-19 pandemic can the study by SIEWEKE et al [1] inform decision-making at an individual or even system wide level?…”

“…Thus, the report of SIEWEKE et al [1] utilising VA-ECMO with Impella support for cardiogenic shock due to influenza in seven patients is important to consider. This very experienced group was unable to achieve any survivors utilising an advanced strategy of VA-ECMO with left ventricular support via an impeller device.…”

“…It seems that in patients with severe respiratory failure, the already available outcome data suggest the use of VV-ECMO will save lives (as seen in the 2009 H1N1 pandemic). What the report of SIEWEKE et al [1] reflects is that, when severe shock develops in the setting of cardiac dysfunction, the use of VA-ECMO with or without additional left ventricular support appears highly unlikely to be lifesaving. Thus, in COVID-19 patients with sepsis and heart failure, avoid undue optimism in conversations with patients and next of kin.…”