Management of dengue myocarditis with impending cardiac arrest in a patient with double valve replacement using VA ECMO-case report

Forty five years morbidly obese male with prosthetic mitral and aortic valve referred to our hospital with dengue shock syndrome. He had recurrent ventricular arrhythmias required multiple shock and short cycle of cardiopulmonary resuscitation (CPR). He was supported with high dose vasopressors and mechanical ventilation. Two-dimensional Echocardiography showed severe left ventricular (LV) dysfunction with left ventricular ejection fraction (LVEF) 8%-10% and mild increase in the gradient across aortic and mitral valve however there was no para-valvular leak or vegetations. Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) was initiated along with continuous renal replacement therapy (CRRT) using Oxiris^® filter in view of persistent ventricular arrhythmia, acute kidney injury (AKI) Grade 3 and severe acute hepatic dysfunction. The major concerns were severe myocardial dysfunction and malignant arrhythmias with impending cardiac arrest warranting the need for VA ECMO support while prosthetic valves especially aortic, uncertainty regarding myocardial dysfunction whether pre-existing or dengue induced and severe dysfunction of other organs were challenges for decision to initiate ECMO. This case describes successful ECMO management and challenges due to prosthetic valve as well as pre-existing severe myocardial dysfunction and concurrent other organ dysfunction.