Use of venoarterial extracorporeal membrane oxygenation in fulminant chagasic myocarditis as a bridge to heart transplant

Abstract

A 17-year-old Brazilian male presented with progressive dyspnea for 15 days, worsening in the last 24 hours, and was admitted in respiratory failure and cardiogenic shock, with multiple organ dysfunctions. Echocardiography showed a left ventricle ejection fraction of 11%, severe diffuse hypokinesia, and a systolic pulmonary artery pressure of 50mmHg, resulting in the need for hemodynamic support with dobutamine (20mcg/kg/min) and noradrenaline (1.7mcg/kg/min). After 48 hours with no clinical or hemodynamic improvement, an extracorporeal membrane oxygenation was implanted. The patient presented with hemodynamic, systemic perfusion and renal and liver function improvements; however, his cardiac function did not recover after 72 hours, and he was transfer to another hospital. Air transport was conducted from Salvador to Recife in Brazil. A heart transplant was performed with rapid recovery of both liver and kidney functions, as well as good graft function. Histopathology of the explanted heart showed chronic active myocarditis and amastigotes of Trypanosoma cruzi. The estimated global prevalence of T. cruzi infections declined from 18 million in 1991, when the first regional control initiative began, to 5.7 million in 2010. Myocarditis is an inflammatory disease due to infectious or non-infectious conditions. Clinical manifestation is variable, ranging from subclinical presentation to refractory heart failure and cardiogenic shock. Several reports suggest that the use of extracorporeal membrane oxygenation in patients presenting with severe refractory myocarditis is a potential bridging therapy to heart transplant when there is no spontaneous recovery of ventricular function. In a 6-month follow-up outpatient consult, the patient presented well and was asymptomatic.

Veno-Arterial Extracorporeal Membrane Oxygenation in Patients with Fulminant Myocarditis: A Review of Contemporary Literature

“…In cases without myocardial recovery, ECMO stabilizes and optimizes cardiogenic shock prior to semi-urgent cardiac transplantation [98]. Multiple case-reports of fulminant myocarditis [99,100] describe successful acute heart transplants in patients who could not be weaned off ECMO. Observational retrospective studies showed that although patients who receive transplant have a relatively high mortality rate, if they do receive a transplant, they have a very high survival rate.…”

Chagas Disease and Heart Failure: An Expanding Issue Worldwide

“…These could be applied as a bridge to transplant, a bridge to recovery during the acute period or as a bridge to decision, or even as destination therapy depending on the general state of the patient and meticulous clinical evaluation of the possibility of survival and better quality of life. [107–110]…”

Seroprevalence of anti-TRYPANOSOMA CRUZI and anti-TOXOPLASMA GONDII antibodies in possible and potential organ donors in the south of Rio Grande do Sul state, Brazil

“…Even so, organ transplantation has increasingly become an important factor in CD transmission. CD transmission rates in organ donors range from 10% to 20%, mainly in heart transplantation (Campos et al, 2016;Durães et al, 2015;Ferreira et al, 2018).…”