acute myocarditis is associated with various electrocardiogram ( ecg ) alterations , including st - t changes , q - waves , atrioventricular- and intraventricular - conduction delays , atrial and ventricular tachyarrhythmia , and low voltage .
fulminant myocarditis with ventricular arrhythmia or atrioventricular block is associated with a high mortality rate .
extracorporeal membrane oxygenation ( ecmo ) is instituted for the management of life threatening pulmonary or cardiac failure , when no other forms of treatment are likely to be successful .
we describe life salvage of ecmo in a patient with cardiogenic shock and malignant arrhythmia caused by acute fulminant myocarditis .
a 53-year - old korean - chinese woman was brought into the emergency department of our hospital by an ambulance , with complaints of progressive chest pain and dyspnea .
she had a high fever , cough , and general fatigue over the three days .
upon arrival , she was fully conscious and had signs of cold sweating , cyanosis and general pallor .
the initial creatine kinase ( ck ) , ck - mb and troponin - i levels were 626 u / l , 47.27 ng / ml , > 50 ng / ml , respecitvely .
emergent coronary angiogram was performed because of low blood pressure ( 88/56 mm hg ) , st - segment depression in the precordial leads of ecg ( fig .
coronary angiographic findings were normal , and an intra - aortic balloon pump ( iabp ) was immediately inserted for hemodynamic support ( fig .
2 ) . on the basis of prodromal symptoms , elevated cardiac enzymes and normal coronary angiographic findings with ventricular wall motion abnormality , we contemplated acute decompensated heart failure due to clinical suspicion acute myocarditis .
she was admitted to the coronary care unit , and mechanical ventilation and inotropic agents were started .
we decided to support the patient with ecmo , which was inserted in a veno - arterial configuration by cannulation on both femoral vessels .
we were able to reduce the amount of inotropic agents using mechanical circulatory support . however , ecg showed wide qrs tachycardia with left bundle branch block ( fig .
3a ) . the serum creatinine level was elevated , and the amount of urination was decreased .
because of low blood pressure and the lack of diuretic effect , continuous renal replacement therapy was started using the ecmo circuit on day 1 .
ventricular wall movement was gradually decreased , and ecg showed little or no electrical activity ( figs .
1d and 3b ) . on day 2 , iabp had to be removed because of its malfunction .
ecg showed little or no electrical activity . on day 5 , ecg revealed weak electrical activities ( fig .
mechanical ventilator was weaned off on day 18 , and ecmo was weaned off on day 20 .
she underwent cardiac magnetic resonance imaging after making sure that she was medically stable , which showed diffuse wall thinning , decreased wall motion and delayed enhancement of diffuse ventricular wall sparing of the infero - septal wall ( fig .
, she was complicated with ischemic insult in the lower extremities , hepatitis with jaundice , and acute tubular necrosis . on day 76 , she was discharged from the hospital .
fulminant myocarditis is an inflammatory process that occurs in the myocardium and has a fatal course due to the rapid development into acute heart failure or cardiogenic shock.1 ) fulminant myocarditis is associated with various ecg alterations , including st - t changes , q - waves , atrioventricular- and intraventricular - conduction delays , atrial and ventricular tachyarrhythmia , and low voltage.2 ) our case demonstrated various alterations of ecg , which are some of the characteristics that are observed in the fulminant myocarditis . at first , ecg showed st segmental changes associated with myocardial ischemia , then ecg showed various manifestations , such as ventricular tachycardia , atrial fibrillation with left bundle branch block , and complete atrioventricular block .
it also displayed very little electrical activity on the whole leads , resembling an ecg after arrest .
low voltage on ecg can be observed in obesity , lung emphysema , pericardial effusion , pulmonary edema , hypothyroidism and amyloidosis , however low voltage on precordial leads , which is less common than on limb leads , implies cardiac tamponade or post - defibrillation state.3 ) low voltage ecg in our case was probably due to pulmonary edema , pericardial effusion and edema of the ventricular wall .
patients presented with syncope , new ventricular arrhythmia or atrioventricular block , ejection fraction of less than 40 percent , and lack of response to usual care within 1 to 2 weeks are associated with a high mortality rate in acute myocarditis.4)5 ) extracorporeal membrane oxygenation is instituted for providing emergent circulatory support to patients with cardiogenic shock .
extracorporeal membrane oxygenation is not only useful for acute decompensated heart failure with low cardiac output , but also for life - threatening arrhythmia.6 ) it provides a bridge - to - recovery or decision regarding either heart transplantation or ventricular assist device .
its adaptation can physiologically reduce wall stress , decrease cytokine activation , and improve myocardial contractility .
however , its use is limited by complications such as thromboembolic events.7 ) it is reported that patients with ischemic insult in the lower extremities or multi - organ failure due to thromboembolic events have poorer prognosis.6 ) long term mechanical circulatory support such as implantable left ventricular assist devices is better treatment modality for advanced heart failure patients with nyha functional class iii b or iv , intermacs level 1 to 5 as a bridge to recovery or bridge to transplantation.8 ) unfortunately the device is not yet commercially abailable in korea . in summary , this patient had multiple factors associated with high mortality , such as low cardiac output and malignant arrhythmia .
in addition , ischemic insults in the lower extremities and multi - organ failure ( lung , kidney and liver ) occurred during intensive therapy .
however , early adaptation of mechanical circulatory support , such as iabp and ecmo , combined with intensive medical therapy could save our patient with high - risk fulminant myocarditis .
 clinical features of acute myocarditis range from a subclinical state to a fulminant state . 
 fulminant myocarditis with ventricular arrhythmia or atrioventricular block is associated with a high mortality rate . in cases in which aggressive medical therapy for fulminant myocarditis is not likely to be successful , intensive and emergency mechanical circulatory support , such as extracorporeal membrane oxygenation ( ecmo ) or intra - aortic balloon pump , 
 should be considered . 
 we report life salvage of acute fulminant myocarditis in a 53-year - old woman presented with malignant arrhythmia and cardiogenic shock supported by ecmo . 