Article

Effects of aortic counterpulsation in 6 cases of fulminant myocarditis

Correspondence / American Journal of Emergency Medicine 33 (2015) 13051322 1315

All patients admitted to the emergency departments with chest pain and ST elevation on electrocardiography should be interrogated for allergic insults.

Birdal Yildirim, MD Department of Emergency Medicine, Faculty of Medicine Mugla Sitki Kocman University, Mugla, Turkey

Corresponding author. Mugla Sitki Kocman Universitesi Tip Fakultesi Orhaniye Mah. Haluk Ozsoy Cad., 48000, Mugla, Turkey

Tel.: +90 252 2115210

E-mail address: [email protected]

Ibrahim Altun, MD Volkan Dogan, MD Mustafa Ozcan Soylu, MD Murat Biteker, MD

Department of Cardiology, Faculty of Medicine Mugla Sitki Kocman University, Mugla, Turkey

http://dx.doi.org/10.1016/j.ajem.2015.04.060

References

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  • Biteker M, Duran NE, Biteker FS, Gunduz S, Gokdeniz T, Kaya H, et al. Kounis syndrome secondary to cefuroxime-axetil use in an octogenarian. J Am Geriatr Soc 2008;56(9):1757-8.
  • Biteker M, Duran NE, Biteker F, Civan HA, Gunduz S, Gokdeniz T, et al. Kounis syndrome: first series in Turkish patients. Anadolu Kardiyol Derg 2009;9(1):59-60.
  • Effects of aortic counterpulsation in 6 cases of fulminant myocarditis

    To the Editor,

    Myocarditis is a myocardial inflammatory disorder characterized by different Etiology and clinical manifestations [1]. The clinical course of patients can vary from asymptomatic/paucisymptomatic forms to fulminant myocarditis (FM), characterized by serious Hemodynamic compromise at presentation that can evolve towards cardiogenic shock (CS). It has been reported that FM has better long-term survival rate than acute myocarditis if the patient survives the acute phase and left ventricular function recovers completely within 1 month [2]. Several evidences highlight the importance of an aggressive diagnostic-therapeutic approach in the acute phase making use of left ventricular assist devices [3] in addition to inotropic drugs. The purpose of this study was to review our experience of patients with FM and the effect of Intraaortic balloon pump on their clinical course and outcome.

    The study group consisted of 6 consecutive patients with FM admitted to our intensive care unit (ICU) from April 2011 to November 2013 and treated with IABP. Clinically suspected myocar- ditis was diagnosed if the patients had at least 1 clinical presentation and at least 1 diagnostic criterion as reported by Caforio et al [1].

    Fulminant myocarditis was diagnosed if the patient showed already at admission:

    Severe heart failure up to CS (defined on the basis of the criteria set by the “SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK?” Trial [4]);
  • Severe diffuse left ventricular dysfunction demonstrated by Transthoracic echocardiography ;
  • Need for high doses of inotropic drugs and Mechanical circulatory support.
  • All patients were previously healthy and referred nonspecific flulike symptoms within the 2 weeks before hospitalization, later resulting in severe onset of ventricular dysfunction and CS. Patient demographics; clinical, laboratory, and instrumental (electrocardiography, echocardiography, cardiac magnetic reso- nance [CMR]) findings; type and effects of management in ICU; and inhospital complications were collected on a standard case-report form. Finally, clinical and echocardiographic follow-up were performed at 21 +- 6 months after hospital discharge.

    In survivor patients, CMR was performed during hospitalization to help diagnosis of clinically suspected myocarditis. At least 2 of the following diagnostic CMR criteria (Lake Louise Criteria) need to be present to suggest myocardial inflammation [5].

    We reported data from 6 patients (Table 1A). Most of these were

    male (4 of 6), and mean age was 34.3 +- 12.4 (range, 24-51) years. At admission, cardiogenic shock was diagnosed in all patients (For- rester class 4). Immediately after admission to ICU, mean ejection fraction (EF), documented with TTE, was 24.6% +- 6%. Invasive blood pressure control was done in all patients; central venous catheter and orotracheal intubation were placed in 4. At the time of hospitalization, all 6 patients were treated with sympathomimetic amines, whose infusion doses were adjusted according to hemody- namic status (Table 1B). In the following hours, after a partial improvement of hemodynamics, we used levosimendan in 5 of 6 patients. Intraaortic balloon pump was implanted within the first 30 minutes after diagnosis of CS without related complications, except in 1 case (patient 4) of femoral artery dissection and consequent right lower Limb ischemia. All 6 patients developed multiorgan failure, documented by cardiac, hepatic, and renal index increases (Table 1C). Within the first 6 hours following IABP implantation, in 4patients, we have documented an improvement of hemodynamic status with systolic blood pressure increase (Fig. 1A) and heart rate reduction (Fig. 1B), an improvement in acid-base balance, and an increase in urine output and EF at TTE. Two patients who did not show a rapid improvement after IABP and aggressive inotropic treatment died. cardiac magnetic resonance, performed in 4 patients, showed typical findings of myocarditis. All survivors showed a recovery of EF at 6-month follow-up (Fig. 1C). At clinical follow-up, all patients were asymptomatic and in good general conditions.

    This study shows that IABP, a widely available support [6], leads to a Rapid resolution of cardiocirculatory shock accompanied by improvement of cardiac function in FM.

    In our experience, echocardiography has played an important role in the diagnosis [7] but particularly in monitoring of therapy and subsequent follow-up. Moreover, CMR has supported the diagnosis because of a better tissue characterization of the myocardium [8]. In our series, within the first 6 hours following IABP implantation, 4 of 6 patients obtained clinical and hemody- namic improvement highlighted by systolic blood pressure increase, heart rate reduction, and increase in urine output even if stimulated by diuretics. Moreover, these patients showed a progressive improvement of left ventricular EF and, after 1-month follow-up, achieved a satisfactory recovery and a good EF value, whereas in the 2 dead patients, IABP did not produce an early improvement. Finally, in our patients, early improvement of the hemodynamics after IABP was a predictor of favorable outcome; and the lack of prompt improvement of hemodynamic status within the first 6 hours from IABP implantation identified a group of patients with worse prognosis.

    1316 Correspondence / American Journal of Emergency Medicine 33 (2015) 13051322

    Table 1

    Patients data

    Demographic and clinical findings

    Sex

    Age

    Blood pressure (mm Hg)

    Heart rate (beat/min)

    Forrester class

    Myoglobin+

    Troponin?

    angiographic findings

    CMR

    Patient 1

    M

    24

    90/40

    140

    4

    248.9

    0.06

    /

    +

    Patient 2

    M

    51

    60/40

    135

    4

    1283

    19.44

    Normal coronary arteries

    +

    Patient 3

    F

    27

    90/50

    140

    4

    332.8

    63.32

    Normal coronary arteries

    +

    Patient 4

    M

    24

    100/50

    130

    4

    689

    68

    /

    +

    Patient 5?

    M

    31

    60/30

    150

    4

    335

    1.51

    /

    /

    Patient 6?

    F

    49

    90/50

    130

    4

    749.3

    43.1

    Normal coronary arteries

    /

    ICU management, IABP durationand use of inotropic drugs

    Patient 1

    Patient 2

    Patient 3

    Patient 4

    Patient 5?

    Patient 6?

    NIV

    +

    +

    +

    +

    IOT

    +

    +

    +

    Invasive blood pressure

    +

    +

    +

    +

    +

    +

    Central venous catheter

    +

    +

    +

    +

    +

    IABP

    +

    +

    +

    +

    +

    +

    IABP duration

    72

    60

    63

    24

    69

    32

    Complications

    /

    /

    /

    Femoral artery dissection

    /

    /

    Dobutamine

    +

    +

    +

    +

    +

    +

    Noradrenaline

    +

    +

    +

    +

    +

    Adrenaline

    +

    +

    +

    +

    +

    +

    Dopamine

    +

    +

    Levosimendan

    +

    +

    +

    +

    +

    Hours in ICU

    432

    240

    216

    960

    168

    33

    in-hospital complications

    SVA

    VF/VT

    Pericardial effusion

    Pleural effusion

    Ascites

    MOF

    Death

    Patient 1

    +

    +

    +

    +

    Patient 2

    +

    +

    +

    Patient 3

    +

    +

    +

    +

    +

    Patient 4

    +

    Patient 5?

    +

    +

    +

    +

    +

    +

    Patient 6?

    +

    +

    +

    +

    NIV = noninvasive ventilation; IOT = orotracheal intubation; SVA = supraventricular arrhythmia; VF = ventricular fibrillation; VT = ventricular tachycardia; MOF = multiple organ failure.

    * Dead patient.

    + Reference: <= 116 ng/mL.

    ? Reference value: <= 0.1 ng/mL.

    Maria Vincenza Polito, MD

    School of Medicine, Department of Medicine and Surgery

    University of Salerno, Salerno, Italy

    Corresponding author

    E-mail address: [email protected]

    Amelia Ravera, MD

    Department of Medicine, University Hospital S. Giovanni Di Dio e

    Ruggi DAragona,Salerno, Italy E-mail address: [email protected]

    Raffaele Mennella, MD

    School of Medicine, Department of Medicine and Surgery

    University of Salerno, Salerno, Italy E-mail address: [email protected]

    Saverio Ferrara, MD Cesare Baldi, MD Rodolfo Citro, MD

    Department of Medicine, University Hospital S. Giovanni Di Dio e

    Ruggi DAragona,Salerno, Italy E-mail addresses: [email protected] (S. Ferrara)

    [email protected] (C. Baldi) [email protected] (R. Citro)

    Marco Di Maio, MD

    School of Medicine, Department of Medicine and Surgery

    University of Salerno, Salerno, Italy E-mail address: [email protected]

    Francesco Vigorito MD Rosario Farina MD

    Department of Medicine, University Hospital

    S. Giovanni Di Dio e Ruggi DAragona,

    Salerno, Italy E-mail addresses: [email protected] (F. Vigorito)

    [email protected] (R. Farina)

    Federico Piscione MD

    School of Medicine, Department of Medicine and Surgery

    University of Salerno, Salerno, Italy E-mail address: [email protected]

    http://dx.doi.org/10.1016/j.ajem.2015.04.087

    References

    1. Caforio AL, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working

      Correspondence / American Journal of Emergency Medicine 33 (2015) 13051322 1317

      140

      Systolic blood pressure (mmHg)

      120

      100

      80

      60

      40

      20

      0

      160

      140

      120

      Heart rate (bpm)

      100

      80

      60

      40

      20

      0

      70

      0h 1h 2h 3h 4h 5h 6h

      Hours

      0h 1h 2h 3h 4h 5h 6h

      Hours

      patient 1

      A

      patient 2

      patient 3

      patient 4 patient 5* patient 6*

      B

      patient 1

      patient 2

      patient 3

      patient 4 patient 5* patient 6*

      C

      60

      Ejection Fraction (EF%)

      Patient 1

      50 Patient 2

      40 Patient 3

      30 Patient 4

      20 Patient 5*

      Patient 6*

      10

      0

      EF 0 EF 1 EF 3 EF 12 EF 24

      Mounths

      Fig. 1. A, Systolic blood pressure (millimeters of mercury) trend in the 6 hours following IABP implantation (*dead patients). B, Heart rate (beat per minute) trend in the 6 hours following IABP implantation (*dead patients). C, Values of EF at admission (EF 0) and at 1-, 3-, 12-, and 24-month follow-up (*dead patients).

      Group on Myocardial and Pericardial Disease. Eur Heart J 2013;34:2636-48 [2648a- 2648d].

      McCarthy RE, Boehmer JP, Hruban RH, Hutchins GM, Kasper EK, Hare JM, et al. Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis. N Engl J Med 2000;342:690-5.

    2. Leprince P, Combes A, Bonnet N, Ouattara A, Luyt CE, Theodore P, et al. Circulatory support for fulminant myocarditis: consideration for implantation, weaning and explantation. Eur J Cardiothorac Surg 2003;24:399-403.
    3. Hochman JS, Buller CE, Sleeper LA, Boland J, Dzavik V, Sanborn TA, et al. Cardiogenic shock complicating acute myocardial infarction-etiologies, management and outcome: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK? J Am Coll Cardiol 2000;36:1063-70.
    4. Friedrich MG, Sechtem U, Schulz-Menger J, Holmvang G, Alakija P, Cooper LT, et al. Cardiovascular magnetic resonance in myocarditis: a JACC white paper. J Am Coll Cardiol 2009;53:1475-87.
    5. Hu W, Liu C, Chen L, Hu W, Lu J, Zhu Y, et al. Combined intraaortic balloon counterpulsation and extracorporeal membrane oxygenation in 2 patients with fulminant myocarditis. Am J Emerg Med 2015;33(5):736.e1-4.
    6. Felker GM, Boehmer JP, Hruban RH, Hutchins GM, Kasper EK, Baughman KL, et al. echocardiographic findings in fulminant and acute myocarditis. J Am Coll Cardiol 2000;36:227-32.
    7. Kramer CM, Barkhausen J, Flamm SD, Kim RJ, Nagel E, et al. Standardized cardiovascular magnetic resonance imaging (CMR) protocols, society for cardiovascular magnetic resonance: board of trustees task force on standardized protocols. J Cardiovasc Magn Reson 2008;10:35.

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