14: Successful Recovery in Fulminant Viral Myocarditis Using ECPR and V-A ECMO: A Case Report

Background: Fulminant myocarditis is a rare but life-threatening condition that can rapidly progress to cardiogenic shock and refractory cardiac arrest. Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a potential rescue strategy in selected patients with refractory arrest. Case Presentation: A 40-year-old previously healthy female presented with fever, fatigue, and shortness of breath for three days. On evaluation, she was hypotensive with signs of poor perfusion. Investigations revealed elevated cardiac biomarkers, global hypokinesia on echocardiography, and cardiogenic shock, leading to a provisional diagnosis of fulminant viral myocarditis. Shortly after admission to the intensive care unit, she developed pulseless ventricular tachycardia and suffered a witnessed in-hospital cardiac arrest. Advanced cardiac life support was initiated immediately. Despite multiple defibrillations and antiarrhythmic therapy, the patient remained in refractory ventricular fibrillation. Given the refractory arrest and favorable premorbid status, ECPR was initiated. Emergent cannulation was performed, and extracorporeal support was established, resulting in return of spontaneous circulation. Neurological assessment following resuscitation revealed intact cerebral function. The patient was managed on venoarterial (VA) extracorporeal membrane oxygenation (ECMO) with vasopressors, inotropes, and mechanical ventilation. Cardiac function progressively improved, and she was successfully weaned from extracorporeal support by day 12. An elective tracheostomy was performed for prolonged ventilatory support, and she was subsequently liberated from mechanical ventilation. Her course was complicated by a right-sided hemothorax due to persistent bleeding from a right intercostal artery, which was managed with embolization followed by video-assisted thoracoscopic surgery. After rehabilitation, the patient was discharged home with preserved neurological and functional status. Conclusion: This case demonstrates successful ECPR in fulminant myocarditis with complete neurological recovery. It highlights the potential role of VA-ECMO as a lifesaving strategy in refractory cardiac arrest secondary to reversible myocardial dysfunction and underscores the need for further research to refine patient selection and management strategies.