Right-Dominant Fulminant Myocarditis Managed With Veno-Arterial Extracorporeal Membrane Oxygenation (ECMO) and Impella Support (EC-PELLA)

Fulminant myocarditis may present with rapidly progressive cardiogenic shock and biventricular failure. Although fulminant myocarditis often presents with global left ventricular (LV) failure, unusual right-ventricular-predominant forms can mimic inferior ST-elevation myocardial infarction (STEMI) and delay diagnosis. Mechanical circulatory support (MCS) is often required, and veno-arterial extracorporeal membrane oxygenation and Impella (EC-PELLA) has been used in select cases. However, guidance is limited regarding its role when recovery is uncertain. A previously well, 72 year old woman collapsed with complete heart block, inferior ST-elevation, and isolated right ventricular dysfunction-features that strongly suggested inferior STEMI, yet angiography was nonobstructive. Despite inotropes and mechanical ventilation, the patient deteriorated, prompting initiation of VA-ECMO. Progressive vasoplegia, end-organ failure, and pulmonary edema necessitated placement of an Impella CP device. Myocardial biopsy confirmed lymphocytic myocarditis. Despite maximal support; there was no LV recovery, and the patient developed multiorgan failure. After multidisciplinary review and family discussions, support was withdrawn. This case illustrates both the diagnostic pitfall of right-dominant fulminant myocarditis masquerading as STEMI and the escalating role of EC-PELLA when shock is refractory, while underscoring the challenge of determining futility in the absence of early recovery. We discuss hemodynamic goals, escalation strategy, and prognostic uncertainty, emphasizing the need for early collaborative decision-making frameworks.