J Korean Med Sci.  2015 Sep;30(9):1367-1372. 10.3346/jkms.2015.30.9.1367.

Pathological Substratum for a Case of Fulminant Myocarditis Treated with Extracorporeal Membrane Oxygenation and Subsequent Heart Transplantation

• Kim IA
• Yang HS
• Kim WS
• Chee HK

• KMID: 2344166
• DOI: http://doi.org/10.3346/jkms.2015.30.9.1367

Abstract

Fulminant myocarditis has been defined as the clinical manifestation of cardiac inflammation with rapid-onset heart failure and cardiogenic shock. We report on the case of a 23-yr-old woman with pathology-proven fulminant lymphocytic myocarditis presenting shock with elevated cardiac troponin I and ST segments in V1-2, following sustained ventricular tachycardia and a complete atrioventricular block. About 55 min of intensive cardio-pulmonary resuscitation, with extracorporeal membrane oxygenation support, bridged the patient to orthotopic heart transplantation. The explanted heart revealed diffuse lymphocytic infiltration and myocyte necrosis in all four cardiac chamber walls. Aggressive mechanical circulatory support may be an essential bridge for recovery or even transplantation in patients with fulminant myocarditis with shock.

Keyword

Fulminant Myocarditis; Complete Atrioventricular Block; Extracorporeal Membrane Oxygenation; Orthotopic Heart Transplantation

MeSH Terms

Combined Modality Therapy/methods
Extracorporeal Membrane Oxygenation/*methods
Female
*Heart Transplantation
Humans
Myocarditis/complications/*diagnosis/*therapy
Shock/*diagnosis/etiology/*prevention & control
Treatment Outcome
Young Adult

Figure

• 

  Fig. 1 Electrocardiograms before the orthotopic heart transplantation. (A) In the emergency room there was a 2:1 atrioventricular block with an elevated ST-T segments at V1-2 and reciprocal ST depression in leads II, III, aVF, and V4-6. (B) Before the ECMO support, there was sustained ventricular tachycardia. (C, D) At hospital days 3 and 4, there was a complete atrioventricular block with a progress of low voltage R waves.

• 

  Fig. 2 Gross findings of the explant heart. The heart measured 10.2×7.8×7.2 cm, and weighed 236 grams. (A) On inspection, the external surface shows multiple petechia-like lesions (black arrows). (B) A longitudinal cut section of the left ventricle (LV) endocardium reveals multiple erythematous and dark hemorrhagic spots (white asterisk). (C) The right ventricle (RV) endocardium shows a bright brown and relatively homogeneous appearance. (D) An axial cut section of both ventricles shows multifocal areas of mottling (empty arrowheads).

• 

  Fig. 3 Histologic findings of the explant heart. (A) Left ventricle, (B) Right ventricle, (C) Left atrium, and (D) Right atrium. Both atrial and ventricular walls show fulminant lymphocytic myocarditis. There are no giant cells or evidence for vasculitis or granulomas (H&E stain ×200).

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