Introduction
Acute myocarditis is one of the relatively common complications of coronavirus disease 2019 (COVID-19), which can lead to serious conditions such as cardiac dysfunctions and cardiogenic shock without appropriate interventions.Reference Ammirati, Lupi and Palazzini1,Reference Haussner, DeRosa and Haussner2 The prevalence of acute myocarditis among the hospitalized COVID-19 patients was 2.4% with biopsy and 4.2% without biopsy confirmation.Reference Ammirati, Lupi and Palazzini1 A systematic review reported the case fatality rate of myocarditis due to COVID-19 was 14%.Reference Haussner, DeRosa and Haussner2
In fulminant myocarditis due to COVID-19 with refractory cardiogenic shock, extracorporeal cardiopulmonary resuscitation (E-CPR) may be indicated.Reference Shekar, Badulak and Peek3 Zeng, et alReference Zeng, Liu and Yuan4 reported the first case of fulminant myocarditis due to COVID-19 receiving extracorporeal membrane oxygenation (ECMO) support who did not recover. Recently, Buitrago, et alReference Buitrago, Munoz, Finkelstein and Mulinari5 reported the first case of COVID-19-induced acute fulminant myocarditis presenting cardiac arrest in a 12-year-old child who successfully recovered with veno-arterial (VA)-ECMO as a bridge to full recovery. However, until now, there was a lack of information about E-CPR on acute myocarditis due to COVID-19, especially on adult patients. This paper reports the first adult case of acute myocarditis due to COVID-19 with cardiac arrest which was successfully treated with VA-ECMO. Written informed consent was obtained from the patient.
Case Report
A 42-year-old previously healthy female who had received a COVID-19 vaccine three times presented to the emergency department in 2022 with chest pain, dyspnea, lethargy, and fever lasting eight days. She was confirmed COVID-19 positive by reverse transcription polymerase chain reaction test with CT value of 17. Upon examination, she had a pulse of 130 beats per minute, blood pressure 80/40mmHg, and oxygen saturations at 90%. Oxygen, peripheral access lines, 0.9% normal saline, and vasoactive and inotropic was given. Electrocardiogram showed significant ST segment elevation in V2-5 (Figure 1). Transthoracic echocardiogram showed the reduction of left ventricular systolic function with normal right ventricular systolic function and dimensions with an ejection fraction (EF) at 25% (Figure 2a). Laboratory findings showed an elevation of some markers: troponin T (3253ng/L); proBNP (10068pg/ml); D-dimer (3470ng/mL); GOT (122U/L); GPT (258U/L); CK (1792U/L); and CK-MB (121U/L). Both acute myocardial infarction and acute myocarditis were suspected.
Figure 1. Electrocardiogram on Admission Significant for ST-Segment Elevations in V2-5.
Figure 2. Echocardiogram Showed: (A) Reduced Left Ventricular Systolic Function with Normal Right Ventricular Systolic Function and Dimensions on Admission; and (B) Recovery of Ventricular Systolic Function and Ejection Fraction on Day 14.
Coronary arteriography showed no stenosis (Figure 3). During the procedure, cardiac arrest occurred with pulseless ventricular fibrillation, which did not respond to defibrillation and cardiopulmonary resuscitation (CPR) for 120 minutes. Then, VA-ECMO was initiated with femoral cannulation at the bedside. The flow was established at 3.2L/minute, remaining mean artery pressure (MAP) at least 65mmHg. When the patient was stable, a back flow cannula was performed.
Figure 3. Normal Function of Coronary Artery on Coronary Arteriography.
Acute myocarditis was diagnosed clinically based on the criteria proposed by the European Society of Cardiology (Brussels, Belgium) in 2013 without myocardial biopsy.Reference Caforio, Pankuweit and Arbustini6 The course of treatment included: vancomycin, imipenem, methylprednisolone, invasive ventilation; and continuous veno-venous hemodiafiltration during VA-ECMO because of uremia and lactic elevation acidosis. Chest x-ray revealed pulmonary edema (Figure 4a) with worsening oxygenation.
Figure 4. Chest X-Ray Showed: (A) Pulmonary Edema on Admission; and (B) Improvements on Day 7.
On hospital Day 3, the patient recovered consciousness. On Day 4, the kidney function improved and the hemodiafiltration was terminated. The hemodynamics stabilized (a pulse pressure was 15mmHg, and MAP was over 65mmHg without vasoactive and inotropic support), and the patient started weaning off VA-ECMO slowly. On Day 7, the patient tolerated clamping ECMO cannula; echocardiogram showed improved left ventricular systolic function with an EF of 60%; chest x-ray was improved (Figure 4b). Decannulation and extubation was performed on the same day. On Day 14, the patient was discharged home from the hospital with stable cardiopulmonary function and the echocardiogram showed the recovery of ventricular systolic function (Figure 2B) and full neurologic recovery.
Discussion
To the authors’ knowledge, this is the first reported adult patient of COVID-19-induced acute myocarditis with cardiac arrest who fully recovered after VA-ECMO support. Conventional CPR was performed for 120 minutes until bedside ECMO could be placed. Despite this delay, due to unavailability of the ECMO team in the hospital, the use of ECMO was decided because of the following reasons: the patient was young; the arrest occurred in a hospital, was witnessed, and high-quality CPR was started immediately, therefore the “no flow time” was zero; and good recovery of neurologic function was expected. The longer the time between cardiac arrest and initiation of E-CPR, the worse the prognosis tends to be. It is reported that only approximately 15% of the patients survive when arrest to E-CPR interval exceeded 40 minutes.Reference Yukawa, Kashiura, Sugiyama, Tanabe and Hamabe7
Because of poor outcomes among cardiac arrest patients due to COVID-19 with conventional CPR, E-CPR may be considered for a certain group of cardiac arrest patients with young age and shockable initial rhythms, particularly when they have reversible conditions such as acute myocarditis. Such patients have relatively favorable outcomes.Reference Shekar, Badulak and Peek3,Reference Shao, Xu and Ma8 Thus, E-CPR can buy time to reverse the reversible conditions. This case had all of these conditions, and it was decided to perform VA-ECMO even after 120 minutes of cardiac arrest.
Acute and fulminant myocarditis requires prompt management, whereas sometimes differentiation of myocarditis from acute myocardial infarction is difficult because of their similar symptoms and test results. Both diseases present typical or atypical chest pain, abnormal ST on electrocardiogram, wall motion abnormalities on echocardiogram, and elevated markers;Reference Fraser, Agdamag and Maharaj9,Reference Inciardi, Lupi and Zaccone10 however, treatments for these two diseases are quite different. Waiting for myocardial biopsy or cardiac magnetic resonance as a definitive diagnosis is unacceptable in critical cases. The European Society of Cardiology proposed criteria for clinical diagnosis to prompt the management of acute myocarditis.Reference Caforio, Pankuweit and Arbustini6 The Chinese expert consensus recommended coronary arteriography to clinically differentiate between them.
Coronary arteriography does not increase a risk of death among myocarditis patients, although it is an invasive test.Reference Wang, Li and Jiang11 In this case, pulseless-ventricular fibrillation suddenly happened during the angiography, but there was no evidence to suggest that cardiac arrest was related to coronary angiography, particularly in cardiogenic shock.
Conclusion
With a successful treatment and complete recovery of neurological function, this was the second reported case of successful recovery from COVID-19-induced acute myocarditis with cardiac arrest, and the first adult case world-wide. This successful case emphasizes the potential role of VA-ECMO in treating COVID-19-related cardiac arrest patients.
Conflicts of interest/funding
The authors declare no conflict of interest. The authors received no funding support.
