On admission, the patient had 36.0°C of body temperature with a heart rate of 130 beats per minute, an oxygen saturation level of 92%, and a blood pressure was 85/50 mmHg. Physical examination showed engorge neck vein, fine crepitation on both lower lung zones, normal heart sounds without murmur, and cold extremities with delayed capillary refill. Initial transthoracic echocardiogram revealed left ventricular dilatation with ejection fraction of 10%. Acute myocarditis was suspected and underwent the insertion of venoarterial extracorporeal membrane oxygenation (VA-ECMO) and intra-aortic balloon pump (IABP) to stabilize hemodynamics. Furthermore, an atrial septostomy procedure was performed to alleviate the pressure on the left ventricle. After 4 days of intensive treatment with mechanical circulatory support, A decision of bridge to orthotopic heart transplant was made.
Transthoracic echocardiogram after VA-ECMO placement revealed severe left ventricular dilation with left ventricular ejection fraction of 19% by biplane method, global wall hypokinesia, right ventricular systolic dysfunction, complete aortic valve closure, mild to moderate secondary mitral regurgitation, and other valves were not significant dysfunction. After adequate decongestion, chest X-ray showed persistent pulmonary infiltration in the right middle lung zone (Figure 1). On the 9th day, the VA-ECMO was switched to biventricular assist device (BiVAD). The patient was then listed for urgent orthotopic heart transplant.