The Effect Of Extracorporeal Membrane Oxygenation For Fulminant Myocarditis In Adults

BackgroundFulminant myocarditis is the most serious and special type of myocarditis,whose incidence rate is about 11% of the acute myocarditis.It is difficult to be detected and develops rapidly.It can cause acute heart failure and malignant electrophysiological activity in the short term(within 24 hours),leading to serious hemodynamic abnormalities and developing respiratory failure and Multiple organ dysfunction syndrome.The mortality rate in acute phase is high,up to 70%-80%.Although the mortality rate of fulminant myocarditis is high,the long-term prognosis tends to be good once the patients go through the early acute phase and stay stable according to the domestic and foreign researches.At present,without the special treatment therapy,doctors treat these patients with drugs to alleviate the symptoms,reduce the heart load to prompt the cardiac function resumed as soon as possible and maintain hemodynamic stable.To treat the patients with fulminant myocarditis,in addition to a variety kinds of vasoactive drugs,the mechanical auxiliary devices can be used often.According to the literatures at home and abroad and our clinical experience,even the optimization of medical treatment is still difficult to make hemodynamic of these patients stable,same to the intra-aortic balloon pump(IABP).Extracorporeal membrane oxygenation(ECMO)as a kind of effective cardiopulmonary support technology,can partly replace the function of the heart and lung and maintain hemodynamic stable according to providing oxygen for the organs.It make the heart to have a rest to recover the function for a good prognosis.Doctors start use ECMO as a kind of the mechanical auxiliary devices to treat the patients with serious since the 1970 s,to be mature the 80 s.At present,the ECMO is not only be used in the surgical field,but also in the area of the respiratory failure and heart failure,widely used in all kinds of urgent treatment of critically ill patients.The ECMO represents the level in a hospital,a region,and even a country in the field of intensive treatment.According to domestic and foreign related researches,the survival rate of the patients with fulminant myocarditis can be up to 60% to 100% with the treatment of ECMO.But the researches are few about ECMO applied in the patients with fulminant myocarditis because of the late application.In this paper,through a retrospective analysis about the clinical data of 12 patients diagnosed with fulminant myocarditis from November 2016 to January 2018 in the first affiliated hospital of Zhengzhou university,we intend to evaluate the application value in such patients,discuss the complications and the effect jointing with other mechanical equipments and provide a reliable basis for the clinical practice,in order to improve the treatment level of adult fulminant myocarditis.Objective(1)To evaluate the clinical efficacy and security of ECMO for fulminant myocarditis in adults.(2)To discuss the effect and prognosis of ECMO in combination with other mechanical equipment for fulminant myocarditis in adults.MethodsWe retrospectively analyze the clinical data of 12 patients diagnosed with fulminant myocarditis from November 2016 to January 2018 in the first affiliated hospital of Zhengzhou university and collect the information of the patient’s general condition before application of ECMO technique,the change in hemodynamic parameters and biochemical indexes before and after ECMO,the application timing of ECMO,the clinical outcomes and complications,the effect and complications of ECMO in combination with other mechanical equipment for fulminant myocarditis in adults.Results1.the general information before application of ECMO: all of the patients had cardiac shock before ECMO and two cases occurred cardiac arrest,10 cases with malignant arrhythmia.5 cases with height or third degree atrioventricular block installed temporary pacemaker.2.the change of biochemical indicators:the values of the serum creatinine(Scr),urea nitrogen(BUN),alanine aminotransferase(ALT)and total bilirubin tend to be down,but the difference did not reach statistical significance.The values of the troponin I(TNI),creatine kinase isoenzyme(CK-MB)tend to go down after the application of ECMO and have a significant difference after 48 hours of the application of ECMO(P<0.05).Before removing ECMO,troponin I,CK-MB,NT-proBNP were obviously improved,and the values had a significant difference(P < 0.05).3.the change in hemodynamic: compared with pre-insertion ECMO,the systolic pressure,diastolic pressure and mean arterial pressure tend to go up and the lactic acid tend to go down and the value has a significant difference(P<0.05).Before removing ECMO,systolic pressure,diastolic pressure and mean arterial pressure,lactic acid were obviously improved,and the values had a significant difference(P < 0.05).4.the index changes of thoracic echocardiography: after insertion of ECMO,the values of LVEF and FS tended to go down.Till 72 hours after ECMO insertion,the values of them tended to increase gradually,but they still did not reach the statistically significant difference.After insertion of ECMO,the values of LVEDD and LVESD gradually increase.Till 96 hours after ECMO insertion,the values of them tended to decrease,but still they did not reach the statistically significant difference.5.complications: 5 cases occured acute kidney injury with continuous renal replacement therapy.1 case occurred lower limb ischaemia,1 cases of lower extremity venous thrombosis,2 cases of cerebrovascular accident,3 cases of hemolysis,1 case of disseminated intravascular coagulation and 6 cases with thrombocytopenia.2 cases had infection,including 1 case of catheter site infection of incision,1 case of sepsis with septic shock.6.the information of combination with other auxiliary equipment: 3 cases inserted with IABP and 5 cases of AKI treated with continuous renal replacement therapy.6 cases treated with breathing machine after the endotracheal intubation.7.clinical outcome: 10 cases withdrawed machine successfully and 9 cases survived.The successful discharge rate was 83% and the hospital survival rate was 75%.2-15 months follow-up,9 cases survived discharge have a normal life without physical strength restriction.Conclusions1.ECMO is an effective mean for fulminant myocarditis in adults and to apply ECMO timingly and prevent the complications is the key to improve the cure rate.2.The application of CRRT in the early phase of AKI may have a positive impact on the improvement of renal function and the prognosis.