Successful use of extracorporeal membrane oxygenation and drotrecogin α in patients with acute life-threatening myocarditis

Acute fulminant myocarditis may present with cardiogenic shock refractory to inotropics and intra-aortic balloon pumping (IABP). Benefit of extracorporeal membrane oxygenation (ECMO) support has been established. The effectiveness of combination with ECMO or IABP and activated protein C (drotrecogin a; Xigris) in treatment has yet to be defined. Four patients presented with congestive heart failure 3-4 days after flu-like symptoms. Chest roentgenograms showed cardiomegaly and bilateral pulmonary infiltrates. Two-dimensional echocardiograms demonstrated severe myocardial dysfunction with left ventricular ejection fraction (LVEF), measured between 18.4% to 27% (mean, 19.5%). Three patients having been treated with the combination of ECMO or IABP and activated protein C were weaned. Follow-up LVEF measured were 39.9%, 43%, 53%, and 55%, respectively. However, 1 patient died a month later because of systemic lupus erythematosus and repeated infection. There were no neurologic sequelae in the 3 survivors. Serological test and myocardial biopsy for Parvovirus B19 was positive in 3 of 4 patients. Use of circulatory support and activated protein C is an effective alternative for acute life-threatening myocarditis.