Extracorporeal Cardiopulmonary Resuscitation With Ventricular Unloading in Fulminant Influenza A (H1N1) Perimyocarditis: A Case Report
Maria Francesca Marchetti, Flavio Frau, Gianfranco De Candia, Emiliano Maria Cirio, Mauro Cadeddu, Michele Porcu, Roberta MontisciBackground
Fulminant perimyocarditis is an uncommon cause of cardiogenic shock and refractory cardiac arrest. We describe Influenza A (H1N1)–associated perimyocarditis managed with a stepwise extracorporeal resuscitation strategy.
Case
A 54‐year‐old woman presented with chest pain, hypoxemia, and cardiogenic shock. Electrocardiography (ECG) showed diffuse ST‐segment elevation. Echocardiography revealed severe biventricular dysfunction and a fibrinous pericardial effusion and coronary angiography excluded obstructive disease. Despite vasoactive support and mechanical circulatory support with microaxial flow pump Impella CP (flow 2.7 L/min.), she deteriorated to Society for Cardiovascular Angiography and Interventions (SCAI) Stage E with pulseless electrical activity (PEA). During automated chest compressions, mechanical circulatory support with femoral Impella CP was rapidly escalated to venoarterial extracorporeal membrane oxygenation (VA‐ECMO). Respiratory polymerase chain reaction (PCR) was positive for Influenza A (H1N1) virus. Antiviral therapy, heparin anticoagulation, ventilation, and organ support were instituted. Hemodynamics stabilized, lactate cleared, and neurological examination after decannulation was intact. Progressive myocardial recovery permitted VA‐ECMO explant on Day 3 and Impella CP removal 24 h thereafter. She was extubated on Day 6 and discharged from intensive care unit (ICU) on Day 10. Cardiac magnetic resonance (CMR) imaging confirmed myocarditis; echocardiography at follow‐up showed preserved biventricular function.
Conclusion
In fulminant perimyocarditis with refractory arrest, rapid activation of an extracorporeal cardiopulmonary resuscitation (ECPR) pathway with early VA‐ECMO—combined with ventricular unloading—can bridge to myocardial recovery and favorable neurological outcome. Regional systems enabling safe transfer under continuous cardiopulmonary resuscitation (CPR) are critical.