INTRODUCTION AND AIMS: Fulminant myocarditis(FM) is a rare and potentially life-threatening medical emergency, account for 10% of acute myocarditis. However, it has a high case-fatality rate of 50%-75%. We experienced a case of FM, which had a catastrophic course including cardiac arrest and subsequent multiple organ failure(MOF).
METHODS: A 22-year-old female patient with myocarditis was admitted to the first affiliated hospital of Chongqing medical university. She had a cardiac arrest at 43 hours after admission,cardiac monitor displayed ventricular tachycardia(VT),temporary pacemaker was implanted immediately,but there was no response. She was diagnosed with FM, successfully started on veno-arterial extracorporeal membrane oxygenation(VA-ECMO) after 2 hours of chest compressions.Although full conventional medical treatment was given, she had progressive MOF(Heart, liver, brain, lung, kidney, coagulation function) and hemodynamic instability,been in a deep coma whose electroencephalogram prompted severe abnormal. Continuous renal replacement therapy (CRRT) was used at 29 hours after her cardiac arrest. She had a serious bleeding and infection during ECMO treatment, and had a total infusion of 14500ml of red blood cell suspension, 17600ml of plasma.
RESULTS: The patient’s neurological responses changed from decerebrate to flexor after 168h, and she responded to verbal commands after another 672h. The patient was well enough to be disconnected from the ventilator after 840h. The patient continued ECMO treatment for 230 hours at the same time combined with CRRT for up to 318 hours. This is the longest time of FM successfully treated by CRRT at present. Subsequently, she exhibited progressive improvement in cardiac function, and successfully recovered from FM and MOF. The patient was discharged from the hospital with alert mental status and normal laboratory tests 108 days after admission.
Summary of laboratory results
| Laboratory test | At arrival | Day 1 | Day 2 | Day 3 |
|---|---|---|---|---|
| MYO (ng/ml) | 160 | 200 | >500 | >3000 |
| CKM (ng/ml) | 29.3 | 41.4 | 67.2 | 295.5 |
| TNI (ng/ml) | 6.98 | 7.68 | >10 | >10 |
| BNP (pg/ml) | 188 | 326 | 867 | >35000 |
| Cr (umol/l) | 50 | --- | 112 | 263 |
| ALT (U/L) | --- | 18 | 85 | 1368 |
| AST (U/L) | --- | 142 | 281 | 2001 |
| K (mmol/l) | 3.7 | 4.7 | 5.4 | 5.7 |
| ECG | Acute high sidewall myocardial injury | Acute high sidewall and anterior myocardial injury | Acute high sidewall and anterior myocardial injury,CRBBB | Acute high sidewall and anterior myocardial injury,CRBBB |
| EF (%) | --- | 56 | 33 | 36 |
| Laboratory test | At arrival | Day 1 | Day 2 | Day 3 |
|---|---|---|---|---|
| MYO (ng/ml) | 160 | 200 | >500 | >3000 |
| CKM (ng/ml) | 29.3 | 41.4 | 67.2 | 295.5 |
| TNI (ng/ml) | 6.98 | 7.68 | >10 | >10 |
| BNP (pg/ml) | 188 | 326 | 867 | >35000 |
| Cr (umol/l) | 50 | --- | 112 | 263 |
| ALT (U/L) | --- | 18 | 85 | 1368 |
| AST (U/L) | --- | 142 | 281 | 2001 |
| K (mmol/l) | 3.7 | 4.7 | 5.4 | 5.7 |
| ECG | Acute high sidewall myocardial injury | Acute high sidewall and anterior myocardial injury | Acute high sidewall and anterior myocardial injury,CRBBB | Acute high sidewall and anterior myocardial injury,CRBBB |
| EF (%) | --- | 56 | 33 | 36 |
Summary of laboratory results
| Laboratory test | At arrival | Day 1 | Day 2 | Day 3 |
|---|---|---|---|---|
| MYO (ng/ml) | 160 | 200 | >500 | >3000 |
| CKM (ng/ml) | 29.3 | 41.4 | 67.2 | 295.5 |
| TNI (ng/ml) | 6.98 | 7.68 | >10 | >10 |
| BNP (pg/ml) | 188 | 326 | 867 | >35000 |
| Cr (umol/l) | 50 | --- | 112 | 263 |
| ALT (U/L) | --- | 18 | 85 | 1368 |
| AST (U/L) | --- | 142 | 281 | 2001 |
| K (mmol/l) | 3.7 | 4.7 | 5.4 | 5.7 |
| ECG | Acute high sidewall myocardial injury | Acute high sidewall and anterior myocardial injury | Acute high sidewall and anterior myocardial injury,CRBBB | Acute high sidewall and anterior myocardial injury,CRBBB |
| EF (%) | --- | 56 | 33 | 36 |
| Laboratory test | At arrival | Day 1 | Day 2 | Day 3 |
|---|---|---|---|---|
| MYO (ng/ml) | 160 | 200 | >500 | >3000 |
| CKM (ng/ml) | 29.3 | 41.4 | 67.2 | 295.5 |
| TNI (ng/ml) | 6.98 | 7.68 | >10 | >10 |
| BNP (pg/ml) | 188 | 326 | 867 | >35000 |
| Cr (umol/l) | 50 | --- | 112 | 263 |
| ALT (U/L) | --- | 18 | 85 | 1368 |
| AST (U/L) | --- | 142 | 281 | 2001 |
| K (mmol/l) | 3.7 | 4.7 | 5.4 | 5.7 |
| ECG | Acute high sidewall myocardial injury | Acute high sidewall and anterior myocardial injury | Acute high sidewall and anterior myocardial injury,CRBBB | Acute high sidewall and anterior myocardial injury,CRBBB |
| EF (%) | --- | 56 | 33 | 36 |
CONCLUSIONS: CRRT was mainly utilized in acute or chronic heart failure with good corrective effect among cardiovascular diseases. It was used for the treatment of FM with VT as the main manifestations has rarely been report. In this case, we observed its remarkable curative effect in FM mainly presenting with VT and cardiac arrest. CRRT continues to stabilize myocardium electrophysiology by stabilizing the body environment, showing the unique and important supportive treatment for FM that is difficult to control for malignant arrhythmias.
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