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• W4224882616 abstract "Since the beginning of the COVID-19 pandemic, fulminant myocarditis (FM) has been recognized as one of the cardiac complications of COVID-19 disease caused by SARS-CoV-2 virus. FM is characterized by life threatening heart failure and cardiogenic shock, and often requires mechanical circulatory support (MCS). While recently there has been a significant interest regarding the rare incidence of COVID-19 vaccine related myocarditis, there is limited data on management of FM associated with COVID19 disease with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). We report a case series of nine patients with COVID-19 disease associated FM who were managed with VA-ECMO at the Cleveland Clinic Health System. From 6/10/20 to 10/28/21, 13 patients were managed on VA ECMO for COVID-19 disease. Nine patients were identified to have FM based on the clinical features, laboratory analyses and imaging findings. Average age of these patient was 40 years. 5 out of the 9 patients had cardiac arrest. The mean duration of VA ECMO support was 6.8 days. 7 out of the 9 patients survived to hospital discharge. The mean total length of stay was 38 days and ICU length of stay was 31 days. All 7 of the patients who survived showed recovery of the ejection fraction post VA ECMO. Of these 9 patients, 8 were unvaccinated and one had received Johnson and Johnson vaccine (see Table 1).Table 1Patient characteristics, laboratory values, ECMO and hospital course and outcome.Patient Number123456789Age (yrs.)225328274668266624SexMFFFMMFMMCOVID-19 vaccination statusNoneNoneNoneNoneNoneNoneJJ Vaccine*NoneNoneCRP (mg/dL)53.926.3234.914.612.92.152.124.8ESR (mm/hr)N/A9N/A271726267N/APeak Troponin T (ng/mL)0.2019.94.35.6<0.0112.161.342.081.88Cardiac ArrestPEA arrestNoPEA arrestNoNoNoPEA arrestVF/VT arrestVF arrestLVEF25%EF 5%36%22%8%20%10%10%15%Duration of VA ECMO5 days9 days5 days10 days6 days*2 days9 days8 days7 daysSurvival to DischargeYesYesNoYesYesNoYesYesYesCOVID-19 treatmentSteroid, remdesivirSteroid, remdesivir, convalescent plasmaSteroid, remdesivir, tocilizumab, IVIGSteroid, remdesivir, IVIGSteroid, IVIG, remdesivirSteroidSteroidSteroidSteroidPost ECMO LVEF55%45%55%55%30%N/A55%50%57%Total Hospital LOS15 days35 days104 days56 days27 days2 days50 days35 days17 daysICU LOS9 days16 days104 days38 days27 days2 days34 days35 days11 daysSex: M = Male; F = Female; ESR Erythrocyte Sedimentation Rate; CRP: C reactive Protein.JJ Vaccine – Johnson and Johnson Vaccine received 6 months prior to fulminant myocarditis in this patient.PEA, pulseless electrical activity; VT, pulseless ventricular tachycardia; VF, ventricular fibrillation.ICU, intensive care unit; LOS, length of stay; LVEF; left ventricle ejection fraction. Open table in a new tab Sex: M = Male; F = Female; ESR Erythrocyte Sedimentation Rate; CRP: C reactive Protein. JJ Vaccine – Johnson and Johnson Vaccine received 6 months prior to fulminant myocarditis in this patient. PEA, pulseless electrical activity; VT, pulseless ventricular tachycardia; VF, ventricular fibrillation. ICU, intensive care unit; LOS, length of stay; LVEF; left ventricle ejection fraction. In our case series, 7 out of 9 patients with FM survived to hospital discharge. Although long-term data on the management and outcomes of FM in COVID-19 is not available, we provide a clear evidence of VA ECMO use and favorable outcome in COVID-19 disease associated FM. Previously, Zeng et al reported the first case of FM requiring ECMO support.1Zeng J.-H. Liu Y.-X. Yuan J. et al.First case of COVID-19 complicated with fulminant myocarditis: a case report and insights.Infection. 2020; 48: 773-777https://doi.org/10.1007/s15010-020-01424-5Crossref PubMed Scopus (314) Google Scholar Subsequently, Papageorgiou et al. and Marcinkiewicz et al also highlighted the role of VA-ECMO in this patient population with both patients surviving.2Papageorgiou J.-M. Almroth H. Törnudd M. van der Wal H. Varelogianni G. Lawesson S.S. Fulminant myocarditis in a COVID-19 positive patient treated with mechanical circulatory support – a case report.Eur Hear J Case Rep. 2021; 5: ytaa523https://doi.org/10.1093/ehjcr/ytaa523Crossref Scopus (10) Google Scholar, 3Marcinkiewicz K. Petryka-Mazurkiewicz J. Nowicki M.M. et al.Acute heart failure in the course of fulminant myocarditis requiring mechanical circulatory support in a healthy young patient after coronavirus disease 2019.Kardiol Pol. 2021; 79: 583-584https://doi.org/10.33963/KP.15888Crossref PubMed Scopus (5) Google Scholar Currently, the incidence of myocarditis after COVID-19 infection is estimated at 150 cases per 100,000 patients and although heavily publicized, the incidence of myocarditis after vaccine administration is rare and the clinical outcome favorable (i.e. not leading to FM). For example, Diaz et al reported the incidence of myocarditis after vaccination at 1 in 100,000 and Montgomery et al reported myocarditis in 23 military personnel out of 2.8 million vaccines administered.4Barbaro R.P. MacLaren G. Boonstra P.S. et al.Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry.Lancet (London, England). 2020; 396: 1071-1078https://doi.org/10.1016/S0140-6736(20)32008-0Abstract Full Text Full Text PDF PubMed Scopus (420) Google Scholar, 5Montgomery J. Ryan M. Engler R. et al.Myocarditis Following Immunization With mRNA COVID-19 Vaccines in Members of the US Military.JAMA Cardiol. 2021; 6: 1202https://doi.org/10.1001/jamacardio.2021.2833Crossref PubMed Scopus (248) Google Scholar Notably studies by Diaz and Montgomery et al demonstrated only a minority of patients with diminished ejection fraction (5/20) and (4/23), respectively, while the 9 cases in our study all presented with an ejection fraction of less than 25%. Suggesting de-novo infection and vaccine induced myocarditis may cause different levels of severity in disease phenotype. In summary, our case series highlights the risk that COVID-19 poses to unvaccinated patients and the severity of FM in COVID-19 disease. We report a favorable survival trend after FM secondary to COVID-19 with VA ECMO support. We also acknowledge that access to this therapy is limited and long-term sequelae of COVID-19 disease and prolonged hospitalization related complications are still underrecognized. The authors declare no conflicts of interest. Authors would like to acknowledge the entire ECMO team at the Cleveland Clinic for providing outstanding clinical care for patients with this life-threatening condition." @default.
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• W4224882616 date "2022-06-01" @default.
• W4224882616 modified "2023-10-15" @default.
• W4224882616 title "Fulminant myocarditis in COVID-19 and favorable outcomes with VA-ECMO" @default.
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• W4224882616 doi "https://doi.org/10.1016/j.resuscitation.2022.04.021" @default.
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