Successful treatment of fulminant myocarditis with mechanical circulatory support

Abstract   A 66-year-old man with acute fulminant myocarditis was supported by a left ventricular assist device (LVAD) for 22 days, and successfully recovered from severe heart failure. Prior to this, he was treated using percutaneous cardiopulmonary support (PCPS) for five days. However, cardiac function was not recovered, so we conducted implantation of the LVAD. It is essential to make an immediate decision regarding LVAD implantation to save patients with fulminant myocarditis.     

Fulminant myocarditis treated with percutaneous cardiopulmonary support system (PCPS).

PURPOSE: Fulminant myocarditis is characterized by rapid and extensive hemodynamic compromise occurring in a previously healthy patient. The patients sometimes require mechanical circulatory support to maintain systemic perfusion. The purpose of this study was to analyze the clinical course of patients with fulminant myocarditis treated with a percutaneous cardiopulmonary support system (PCPS). PATIENTS AND METHODS: From January 1998 to November 2006, four fulminant myocarditis patients were admitted to the intensive care unit (ICU) in Gunma University Hospital and treated with PCPS to support deteriorating hemodynamics. The mean age of the 4 was 38 +/- 18 (range 14 to 57) years. None of the patients had a past history of heart disease, and the diagnosis of fulminant myocarditis was made with clinical findings and endomyocardial biopsy. Three patients were successfully removed from PCPS; one was not removed and died from cerebral bleeding. Changes in clinical findings, APACHE II scores, and laboratory data were analyzed in the 3 survivors and 1 nonsurvivor. RESULTS: Intra-aortic balloon pumping (IABP) was used in all 4 patients. The duration of PCPS support was 141, 228, and 266 h in the survivors and 330 h in the nonsurvivors. The interval between the occurrence of clinical symptoms such as fever and general fatigue and the induction of PCPS in the nonsurvivor was shorter (2 days) than in the survivors (4-6 days). Cardiac troponin I (cTnI) and creatine phosphokinase (CPK)-MB levels were significantly higher in the nonsurvivor compared with those in the survivors. Left ventricular ejection fraction (LVEF) gradually improved, and PCPS flow was decreased at around 120 h after PCPS start in the survivors; however, these improvements did not occur in the nonsurvivor. CONCLUSION: PCPS was induced in 4 fulminant myocarditis patients and successfully removed from 3 after long-term PCPS (>5 days). The maintenance of hemodynamics, especially in the acute phase of fulminant myocarditis, is important because the possibility of circulatory recovery is relatively high compared with those having severe cardiac failure resulting from other causes. The prognosis might be poor if the interval between the occurrence of clinical symptoms and PCPS deployment is short.     

Support for temporary homecoming of a patient with ventricular assist device

A 19-year-old woman suffered from fulminant myocarditis by Mycoplasma infection, and intra-aortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) were initiated. As the cardiac function was not recovered, the ventricular assist device (VAS) was implanted. Rehabilitation training was started such as maintaining standing position at the bedside, and walking. The preparatory training program for homecoming was conducted twice with VAS. She strongly hoped for participation of coming-of-age ceremony in Tachikawa City that is 3 hours' drive from our hospital. The patient stayed 1 night at home with a doctor and a medical engineer. There was no adverse event. In Japan, the community support of patients with VAS is not yet established and we hope that our experience will be of some help in supporting the homecoming of patients with VAS.     

A case of fluminant myocarditis with fetal pulmonary edema even after introduction of bi-ventricular assist devices

A 15-year-old man developed cardiopulmonary dysfunction 4 days after flu-like symptom, and was transfered to our hospital and diagnosed as a fulminant myocarditis (FM). Intraaortic ballon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) were immediately initiated. However, cardiac function did not recover until 7 days after admission to the ICU, and bilateral ventricular assist devices (BiVAD) were introduced with extracorporeal membrane oxygenation (ECMO). Right ventricular assist device (RVAD) with ECMO was established by right atrial blood withdrawal and pulmonary arterial blood supply using centrifugal pump. After operation of BiVAD, to main LVAD flow, frequent blood-and-fluids volume loading and increase in RVAD flow were necessary due to postoperative bleeding and massive foamy sputum. However, even after hemostasis had been established, the pulmonary edema continued and it was difficult to maintain LVAD flow because of endless transudation from the lungs. Eventually, he developed MOF and passed away 9 days after the admission to ICU. As in cases of end-stage dilated cardiomyopathy, outflow of RVAD into the left atrium instead of the pulmonary artery was demonstrated effective in avoiding trans-pulmonary leakage, and outflow of RVAD into the left atrium may be beneficial to patients with FM who need BiVAD but suffered severe pulmonary edema.     

Emergency Cardiopulmonary Bypass Support in Patients with Cardiac Arrest Caused by Myocardial Infarction

Abstract: Emergency percutaneous cardiopulmonary bypass support (PCPS) was instituted in 3 patients with acute myocardial infarction in cardiac arrest refractory to conventional resuscitation measures. All had severe double or triple vessel disease. Percutaneous transluminal coronary angioplasty (PTCA) was performed in 1 patient, and PTCA and directional coronary atherectomy (DCA) were performed in the other 2 patients on combined intraaortic balloon pumping (IABP) and PCPS. Flow rates of 2 to 5 L/min were achieved, with restoration of mean arterial pressure to more than 60 mm Hg during PCPS. The status of all patients was improved hemodynamically with PCPS. One patient died of hemorrhage during PCPS.
DCA was successfully performed in the other 2 patients, and PCPS and IABP was discontinued. Time on PCPS ranged from 10 h to 8 days. Time on IABP ranged from 10 days to 2 weeks. These 2 patients died of pneumonia or multiorgan failure after 1. 5 months. In conclusion, emergency PCPS is a powerful resuscitative tool that may stabilize the condition of patients in cardiac arrest to allow for definitive intervention.     

Successful surgical management of papillary muscle rupture following acute myocardial infarction in an elderly patient

Papillary muscle rupture is rare but catastrophic complication of acute myocardial infarction. We report a 91-year-old woman who underwent successful management of papillary muscle rupture following acute myocardial infarction. She was transferred to our hospital because of severe pulmonary edema and cardiogenic shock. Echocardiography revealed severe mitral valve regurgitation due to total rupture of anterolateral papillary muscle. After intubation, intraaortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) insertion, mitral valve replacement was successfully performed. She was discharged 134 days after operation. In papillary muscle rupture deteriorating hemodynamics, early diagnosis and immediate cardiopulmonary support are required before surgical treatment. She was, to the best of our knowledge, the oldest among the reported cases of successful surgical treatment of papillary muscle rupture in Japan.     

Risk factors for the surgical repair of ventricular septal perforation; an 8-year multiinstitutional analysis

OBJECTIVE: The purpose of this study was to determine the surgical outcomes and risk factors for surgical repair of the ventricular septal perforation (VSP). METHOD: From 1995 to 2003, 41 patients with VSP underwent surgical repair. There were 18 males and 23 females, with the mean age of 71.7 +/- 9.2. Sixteen patients (39.0%) had the preoperative shock, while 30 patients received intraaortic balloon pumping (IABP) assistance and 1 of those required percutaneous cardiopulmonary support (PCPS). Mean durations from onset of myocardial infarction and VSP to operation were 5.8 +/- 9.4 and 2.4 +/- 8.1 days, respectively. Twenty-six patients underwent infarct exclusion technique, 11 underwent patch closure, and 4 Daggett operation. Mean cardiopulmonary and aortic cross-clamp time were 211 +/- 85 and 105 +/- 43 minutes, respectively. RESULTS: Thirty days mortality was 11 (26.8%). Nine patients (22%) required PCPS after repair, however, 2 weaned off the support and only 1 discharged the hospital. Residual shunt was found in 12 patients (29.3%), and 4 underwent the reclosure of the residual shunt 13 +/- 8.6 days after the initial operation, whereas none of patients with PCPS had residual shunt. Univariate analysis revealed the preoperative shock (p = 0.03), longer cardiopulmonary bypass time (p < 0.01), and the need for PCPS after repair (p < 0.01) were the risk factors for the early mortality. Multivariate analysis indicated the cardiopulmonary time over 210 minutes and the need for PCPS to be the significant risk factors. CONCLUSION: The long cardiopulmonary bypass support after repair and the subsequent need for PCPS imply the poor left ventricular function. Since the residual shunt was not the cause of PCPS, the surgical outcome for VSP may be limited in patients with poor left ventricular function. In these patients, other therapeutic strategies may be required, such as ventricular assisting devices, transplantation, or regenerative therapy.     

Clinical experience of a percutaneous ventricular support for profound heart failure following acute myocardial infarction--a case report]

Percutaneous biventricular support with centrifugal pump was applied to a 59-year-old man with profound heart failure following acute myocardial infarction. Direct coronary angioplasty was performed under percutaneous cardiopulmonary support (PCPS). After angioplasty, he could not be weaned from PCPS under IABP. We used percutaneous left ventricular support (PLVS) with transseptal left atrial cannulation. PLVS could not maintain effective assist flow and he developed a cardiogenic shock again. PCPS was added to PLVS, and percutaneous biventricular support was started. Assist flow ranged 1.7-3.0 L/min in PLVS, and 1.7-2.0 L/min in PCPS, and total assist flow was 3.4 L/min. Pulsatile pressure was obtained by adding IABP. The patient was successfully weaned from PCPS in 26 hours and PLVS in 118 hours. Patient is alive and well one year after PLVS. Combination of PLVS and PCPS is an effective ventricular support system, being less invasive than conventional method with thoracotomy, and may be useful for profound heart failure.     

Infarct exclusion for postinfarction left ventricular free wall rupture with severe congestive heart failure

A 70-year-old man was transferred to our hospital with severe congestive heart failure and ventricular arrhythmia due to acute myocardial infarction. He had experienced chest pain 3 weeks previously and was admitted to another hospital for dyspnea, where he required assist ventilation, 1 week prior to the transfer. An echocardiogram revealed a broad anteroseptal infarction and very poor left ventricular function with an ejection fraction (EF) of 22%. He remained in a severe congestive heart failure condition despite a full administration of catecholamines. Coronary angiogram findings revealed an occlusion of the proximal left anterior descending coronary artery and 1 week later severe hypotension was suddenly presented. An echocardiogram showed pericardial effusion with signs of cardiac tamponade. A pericardiocentesis was performed and hemodynamic improvement was obtained for a short time, after which the patient underwent urgent open heart surgery. During the operation, exclusion of the anteroseptal akinetic area using an oval patch was performed under a cardiopulmonary bypass and ventricular fibrillation. Severe cardiac failure remained postoperatively and the patient could not be weaned from cardiopulmonary bypass, therefore, we implanted a percutaneous cardiopulmonary support (PCPS) and started intraaortic balloon pumping (IABP). The patient was weaned from PCPS at 26 days after surgery and from IABP at 30 days. Following hospital release, he has continued to do well without heart failure for 39 months after the operation.     

Beating heart coronary artery bypass grafting for acute myocardial infarction

We consider that off-pump coronary artery bypass grafting (CABG) [OPCAB], which results in local myocardial ischemia, is more effective for patients with acute myocardial infarction (AMI) than conventional CABG under cardiac arrest with global myocardial ischemia. Twenty-one patients (15 males, 6 females) received OPCAB for AMI, among whom surgery was performed following percutaneous coronary intervention (PCI) failure in 4 and PCI was performed prior to OPCAB in 2, while PCI was not performed in the remaining 15. Preoperatively, 16 patients had intraaortic balloon pumping (IABP), and 4 had IABP and percutaneous cardiopulmonary support (PCPS). The mean interval from onset to surgery was 11.7 (range 3 to 40) hours. In 20 cases, a complete revascularization was performed. The mean number of bypasses was 2.3 and OPCAB was carried out in 14 patients. In 2 cases, OPCAB was converted to on-pump beating CABG for complete revascularization. Fourteen patients (67%), each maintained with preoperative left ventricular ejection fraction (EF), were discharged with an elective bypass. Four patients died after on-pump beating CABG, in whom EF was lower than 10%. In addition, 3 died of low cardiac output syndrome (LOS) under PCPS and 1 of ventricular fibrillation. Based on our results, we considered that complete revascularization using OPCAB was effective for cases of AMI with PCI difficulty. However, in shock cases requiring PCPS, cardiac function was not improved even after revascularization. Therefore, it is necessary to study new procedures for shock cases during the period from onset to surgery.     

Acute massive pulmonary thromboembolism treated with percutaneous cardiopulmonary support perioperatively

A 57-year-old female was transferred to our hospital because of sudden dyspnea. She was hypotensive and hypoxic. Acute massive pulmonary thromboembolism was detected by echocardiography and computed tomography (CT). Before the operation, she fell into severe shock and needed cardiopulmonary resuscitation. We applied percutaneous cardiopulmonary support (PCPS), and performed emergency open embolectomy under total cardiopulmonary bypass. Because of the right ventricular failure, she could not be weaned from total cardiopulmonary bypass. PCPS was required again and used continuously during postoperative management. Her cardiopulmonary state improved gradually. PCPS was stopped at 6 days after surgery, and she was extubated at 14 days after surgery. PCPS was very useful for resuscitation and stabilization of the cardiopulmonary function for acute massive pulmonary thromboembolism perioperatively.     

Strategy of circulatory support with percutaneous cardiopulmonary support

We evaluated the efficacy and problems of circulatory support with percutaneous cardiopulmonary support (PCPS) for severe cardiogenic shock and discussed our strategy of mechanical circulatory assist for severe cardiopulmonary failure. We also described the effects of an alternative way of PCPS as venoarterial (VA) bypass from the right atrium (RA) to the ascending aorta (Ao), which was used recently in 3 patients. Over the past 9 years, 30 patients (20 men and 10 women; mean age: 61 years) received perioperative PCPS at our institution. Indications of PCPS were cardiopulmonary bypass weaning in 13 patients, postoperative low output syndrome (LOS) in 14 patients, and preoperative cardiogenic shock in 3 patients. Approaches of the PCPS system were the femoral artery to the femoral vein (F-F) in 21 patients, the RA to the femoral artery (RA-FA) in 5 patients, the RA to the Ao (RA-Ao) in 3 patients, and the right and left atrium to the Ao in 1 patient. Seventeen (56.7%) patients were weaned from mechanical circulatory support (Group 1) and the remaining 13 patients were not (Group 2). In Group 1, PCPS running time was 33.1 +/- 13.6 h, which was significantly shorter than that of Group 2 (70.6 +/- 44.4 h). Left ventricular ejection fraction was improved from 34.8 +/- 12.0% at the pump to 42.5 +/- 4.6% after 24 h support in Group 1, which was significantly better than that of Group 2 (21.6 +/- 3.5%). In particular, it was 48.6 +/- 5.7% in the patients with RA-Ao, which was further improved. Two of 3 patients with RA-Ao were discharged. Thrombectomy was carried out for ischemic complication of the lower extremity in 5 patients with F-F and 1 patient with RA-FA. One patient with F-F needed amputation of the leg due to necrosis. Thirteen patients (43.3%) were discharged. Hospital mortality indicated 17 patients (56.7%). Fifteen patients died with multiple organ failure. In conclusion, our alternate strategy of assisted circulation for severe cardiac failure is as follows. In patients with postcardiotomy cardiogenic shock or LOS, PCPS should be applied first under intraaortic balloon pumping (IABP) assist for a maximum of 2 or 3 days. In older aged patients particularly, the RA-Ao approach of PCPS is superior to control flow rate easily, with less of the left ventricular afterload and ischemic complications of the lower extremity. If native cardiac function does not recover and longer support is necessary, several types of ventricular assist devices should be introduced, according to end-organ function and the expected support period.     

Successful resuscitation of intractable hyperkalemic cardiac arrest

We report on a 42-year-old oliguric uremic man on regular hemodialysis who developed sudden cardiac arrest, secondary to severe hyperkalemia, with a plasma potassium concentration of 9.7 mEq x l(-1). The cardiac arrest persisted after the initiation of cardiopulmonary resuscitation and intensive treatment for marked hyperkalemia for an hour and 55 minutes. Therefore a portable percutaneous cardiopulmonary support (PCPS) system had to be instituted while the patient had very prolonged refractory ventricular fibrillation. His cardiac rhythm was restored immediately after application of PCPS and he recovered without neurological sequelae. We therefore suggest that PCPS should be considered as a therapeutic option during cardiopulmonary resuscitation for life-threatening cardiac arrest secondary to severe hyperkalemia.     

Cerebral tissue oxygen saturation during percutaneous cardiopulmonary support in a canine model of respiratory failure

Percutaneous cardiopulmonary support (PCPS) has come to be applied for cardiopulmonary resuscitation and in the management of severe respiratory failure as well as severe heart failure. We investigated cerebral tissue oxygen saturation during PCPS in a canine model of respiratory failure using near-infrared spectroscopy. Animals were mechanically ventilated with 10% oxygen to make a respiratory failure model. Perfusion with PCPS was performed via the left femoral artery and switched to that via the right axillary artery. Cerebral tissue oxygen saturation was 54.2 +/- 3.4% during PCPS via the femoral artery and was 82.3 +/- 4.6% during PCPS via the axillary artery (p = 0.001). Hepatic tissue oxygen saturation was not significantly different. LV dP/dt max increased significantly after switching to the axillary blood supply (p = 0.001). Conventional PCPS may not have the capability of supporting cerebral circulation under severe respiratory failure without organic heart disease.     

An Aortic Balloon Catheter Incorporating a Conduit for Percutaneous Cardiopulmonary Support

Circulatory support using both intraaortic balloon pumping (IABP) and percutaneous cardiopulmonary support (PCPS) can improve general hemodynamics; however, sometimes brain damage occurs caused by hypoperfusion. Such cerebral hypoperfusion is likely to be caused by PCPS when applying the conventional femoral cannulation. We have developed a new IABP catheter which incorporates a conduit for PCPS with an outlet at the catheter tip, the goal of which is the improvement of cerebral perfusion. The hemodynamic characteristics of this new IABP catheter were compared with those of the conventional combination of IABP and PCPS. Studies were performed by mock test using a pulsatile artificial heart. A polyvinyl chloride tube acted as the aorta with 2 branches at the proximal and distal portions representing the upper and lower portions of the body. The IABP balloon was positioned between the 2 branches, and changes in flow at the 2 branches were examined at varying PCPS flow rates. Flow in the proximal branch using the new device was greater than it was using the conventional PCPS device. We conclude that cerebral perfusion could be improved with the use of this new special IABP catheter.     

Clinical Experience with the Nikkiso Centrifugal Pump

Abstract: The Nikkiso HPM-15 is a minimally sized centrifugal pump. Preliminary results regarding clinical use of this pump for cardiopulmonary bypass (CPB) procedures have been reported previously. Recently, we have managed some additional cases using a newly developed controller. This article reports our clinical experiences with the use of this pump. We have managed 23 cases with a Nikkiso centrifugal pump. Twenty-two patients underwent CPB and 1 patient with fulminant viral myocarditis underwent percutaneous cardiopulmonary support (PCPS). With this pump, the circuit was extremely easy to prepare and deaeration was achieved readily. Hemodynamics during CPB and PCPS were stable in all cases. The increase in serum-free hemoglobin levels during CPB with this pump was as low as that seen in preliminary tests. A decrease in the platelet count was observed after the initiation of CPB with this pump; however, platelet counts returned to preoperative values 7 days after surgery. Moreover, urine output during CPB with this pump was as high as that seen in preliminary tests. No abnormalities in renal or liver function occurred during CPB. It appears that this new centrifugal pump is safe and easy to operate, and we conclude that it is useful for CPB and PCPS.     

Two cases using "epi-endocardial patch repair" for postinfarction left ventricular rupture

The treatment points of left ventricular (LV) free wall rupture after acute myocardial infarction (MI), so far, are to prevent a deterioration of LV function after MI and to prevent a recurrence or extension of the dissection of the infarcted/necrotic myocardium to stop bleeding. We report two cases of LV rupture after myocardial infarction that underwent epicardial patch repair using deep epicardial sutures reaching LV subendocardial area ("epi-endocardial patch" repair). The procedure was done under beating condition with cardiopulmonary bypass in the first case and with preoperatively percutaneous cardiopulmonary support system (PCPS) in the second case to prevent a deterioration of LV function. Hemostasis was effective and complete, and extension of the intramuscular dissection was well blocked. The patients recovered LV function soon. The epi-endocardial sutures can be placed safely without inducing new ischemia, and the method might be possible with beating condition.     

Transport of Hemodynamically Unstable Patients by a Mobile Mechanical Circulatory Support Team

Abstract: Advances in medical technology have made it possible to use emergency femoro-femoral bypass (FFB) for transport of hemodynamically unstable patients. In this study, we report on our experience of transport of patients with refractory heart failure by a special mobile mechanical circulatory support team (MMCST) using an intraaortic balloon pump (IABP) or FFB. A total of 22 patients (14 men, 8 women) were supported by the MMCST and transported to our clinic for further diagnostic or therapeutic procedures. The diagnoses in 12 patients was acute myocardial infarction, in 7 patients, di-latative cardiomyopathy (DCM), and in 3 patients, acute fulminant myocarditis. In 15 cases, FFB was implanted (5 in combination with IABP), and in 5 cases, IABP only was implanted. Two patients received maximal dosages of catecholamines. After arrival at our clinic, 11 patients received implants of a more sophisticated support system. From the myocardial infarction group, 3 patients received coronary artery bypass grafting, 1 patient received percutaneous transluminal coronary angioplasty, and 1 patient received heart transplantation as final therapy. In the myocarditis and DCM groups, 7 patients underwent heart transplantation. Finally, 11 patients (50%) survived, and 11 patients died of multiorgan failure or septicemia.     

Study of Regional Cerebral Oxygen Saturation During Percutaneous Cardiopulmonary Support

Abstract: The purpose of this study was to evaluate the change of regional cerebral oxygen saturation (rSo₂) during percutaneous cardiopulmonary support (PCPS) in patients with cardiogenic shock. Fifteen patients with cardiogenic shock were evaluated during PCPS by continuous monitoring of rSo₂, systemic venous oxygen saturation (Svo₂), and hemodynamics. The brain damage of these patients was also evaluated during and after PCPS. There were 10 males and 5 females. Their ages ranged from 57 to 79 years old (average: 60.0 ± 14). Two patients were unconscious before PCPS, and 11 received intraaortic balloon pumping (IABP) before PCPS. The change of rSo₂was significantly correlated with the change of Svo,. The average of rSo₂was 64 ± 3% at the stable hernodynamic condition. The rSo₂with pulsatile PCPS was higher than that with nonpulsatile PCPS. There was no correlation between brain damage and rSo₂. The patients with low rSo₂(40%) that resulted in poor LV function could not be weaned from PCPS. In conclusion, the continuous monitoring of rSo₂during PCPS could be a useful tool.     

Assessment of myocardial recovery in a patient with acute myocarditis supported with a left ventricular assist device: a case report.

Acute myocarditis may present with profound hemodynamic compromise; however, spontaneous resolution of the inflammatory process may occur in up to half of such patients. In patients with fulminant myocarditis, mechanical circulatory support may serve as a bridge to myocardial recovery. In this report we describe a 35-year-old man with acute myocarditis who required left ventricular assist device support as a bridge to recovery, and suggest a method for determining the suitability and timing of device explantation. A combination of echocardiography, right heart catheterization, exercise testing and serial endomyocardial biopsies was used to determine the resolution of myocarditis, recovery of myocardial function and timing for device explantation. Successful device explantation was performed after 37 days of device support. Further study is required to assess the role of ventricular assist devices in combination with immunosuppressive therapy in the management of fulminant myocarditis.