Management
        During the initial diagnosis of cardiogenic shock, hemodynamic stability was maintained through using mechanical circulatory support. Medical management involved the administration of inotropic drugs. The antibiotics and antiviral prescribed included ceftriaxone, azithromycin, doxycycline, and oseltamivir to cover potential causes of myocarditis. After the VA-ECMO insertion, the dosage of inotropic drugs could be gradually reduced while still maintaining adequate hemodynamics. Hemodynamic parameters, mechanical circulatory support, and inotropic agents are summarized in Table 1.
        On the 10th day after BiVAD insertion, the patient’s hemodynamics deteriorated even though BiVAD function remains normal and there were no mechanical complications on echocardiogram found. Higher vasopressor doses were required to maintain mean arterial pressure. Persistent pulmonary infiltration raised suspicion of VAP with septic shock. Empiric antibiotics were administered, including meropenem, vancomycin, levofloxacin, trimethoprim-sulfamethoxazole, and colistin. After the BAL results came back. Antibiotics were changed to meropenem, tigecycline, levofloxacin, and voriconazole. Fortunately, after implementing intensive management, the patient’s hemodynamics improved within 24 hours. This positive response led to an urgent orthotopic heart transplant. However, due to active VAP with septic shock within the past 24 hours as well as the diagnosis of probable IPA, a lower immunosuppressive regimen was chosen. This regimen consisted of intravenous methylprednisolone 500 mg and oral mycophenolic acid 540 mg administered prior to the operation.
        After the 20th day, the patient underwent orthotopic heart transplant. The explanted heart’s pathological examination revealed dilated cardiomyopathy without a specific etiology, leading to the diagnosis of idiopathic dilated cardiomyopathy (Figure 5).
        Following the successful transplant, the overall clinical condition showed improvement, enabling the removal of all mechanical circulatory support and the discontinuation of antibiotics within 7 days. Voriconazole was continued to treat probable IPA, in addition to immunosuppressive drugs such as tacrolimus, mycophenolic acid, and prednisolone.
Table 1 Hemodynamic parameters, mechanical circulatory support, and inotropic agents during admission.