Discussion
Here, we report a case of fulminant myocarditis that recovered with no
neurological damage at all after 38-h asystole. To our knowledge, this
is the first reported case of fulminant myocarditis that recovered from
long-term asystole. Cardiac function in fulminant myocarditis is often
reversible and improves after overcoming the acute phase, although
patients who suffered cardiac arrest have a poor prognosis, even with
ECMO or IABP. There is also no established consensus on the
reversibility of myocardial function, except in specific environments,
such as cardiac surgery under cardiopulmonary bypass. This case
suggested that there is a possibility of subsequent improvement, even
after prolonged asystole.
In fulminant myocarditis, temporary cardiopulmonary support is an
important treatment approach as cardiac function can be restored
following the acute phase. An observational study assessing fulminant
myocarditis found that ECMO was equivalent to ventricular assist devices
(VAD) and easier to introduce. Moreover, in fulminant myocarditis
complicated by malignant ventricular arrhythmias, left VAD is unlikely
to provide sufficient hemodynamic support when the right ventricle does
not work effectively, whereas ECMO effectively bypasses biventricular
failure. ECMO is the first treatment option for catastrophic myocarditis
owing to low invasiveness, mobility for bedside implementation, and
utility during cardiopulmonary resuscitation in cardiac arrests.
The concurrent use of devices such as VA-ECMO with IABP or Impella,
rather than VA-ECMO alone, in patients with severe heart failure and
cardiogenic shock may reduce the left ventricle load, minimize
myocardial injury, and improve clinical outcomes. In severe cardiac
dysfunction, the aortic valve does not open even when circulation is
adequately secured by retrograde perfusion with VA-ECMO, and left
ventricular thrombosis is a concern. The combination of IABP and V-A
ECMO may reduce the risk of left ventricular thrombus by maintaining
physiological antegrade blood flow 9. However, despite
the theoretical advantage, the effectiveness of the combined use of IABP
and V-A ECMO, is inconclusive. Several observational studies have shown
conflicting results, and there are currently no randomized trials10. In this case, the risk of ventricular thrombosis
was significantly high when circulation was supported by V-A ECMO only,
as no antegrade blood flow was generated during asystole. Therefore,
additional use of IABP might have been effective for preventing
intraventricular thrombosis and reducing light ventricular load in the
present case, which might result in the recovery of cardiac function.
Regrettably, the current cause of fulminant myocarditis was not
identified; however, this case illustrates that cardiac function might
be restored even after prolonged asystole with adequate hemodynamic
support.