Mechanical Unloading by Fulminant Myocarditis: LV-IMPELLA, ECMELLA, BI-PELLA, and PROPELLA Concepts

Carsten Tschöpe,Burkert Pieske,Sophie Van Linthout,Thomas Mairinger,Florian Krackhardt,Frank Spillmann,Oliver Klein,Evgenij V Potapov,Gunther Schmidt,Daniel Burkhoff

doi:10.1007/s12265-018-9820-2

Abstract

Mechanical circulatory support (MCS) is often required to stabilize patients with acute fulminant myocarditis with cardiogenic shock. This review gives an overview of the successful use of left-sided Impella in the setting of fulminant myocarditis and cardiogenic shock as the sole means of MCS as well as in combination with right ventricular (RV) support devices including extracorporeal life support (ECLS) (ECMELLA) or an Impella RP (BI-PELLA). It further provides evidence from endomyocardial biopsies that in addition to giving adequate support, LV unloading by Impella exhibits disease-modifying effects important for myocardial recovery (i.e., bridge-to-recovery) achieved by this newly termed “prolonged Impella” (PROPELLA) concept in which LV-IMPELLA 5.0, implanted via an axillary approach, provides support in awake, mobilized patients for several weeks. Finally, this review addresses the question of how to define the appropriate time point for weaning strategies and for changing or discontinuing unloading in fulminant myocarditis.

Highlights

The diagnosis and treatment of myocarditis is still a clinical challenge due to the variability of its clinical presentation ranging from mild dyspnea or chest pain to cardiogenic shock and death [1]
We provide an overview of the successful use of an Impella-based strategy for treatment of fulminant myocarditis and cardiogenic shock as a sole means of supporting the circulation, and in combination with extracorporeal life support (ECLS) (ECMO plus Impella: ECMELLA), or in combination with right ventricle (RV)-Impella RP (BI-PELLA)
For the first time to our knowledge, the impact of a left ventricle (LV)-Impella 5.0 implanted through an axillary approach for 39 days combined with standard heart failure therapy, which does not represent a causal therapy, and immunosuppressive therapy consisting of prednisolone (starting at 1 mg/kg/day for 4 weeks followed by 10 mg/day weaning all 2 weeks until reaching 10 mg/day maintenance dose), and azathioprine (100 mg/day) in a patient presenting with fulminant myocarditis and cardiogenic shock

Summary

Introduction

The diagnosis and treatment of myocarditis is still a clinical challenge due to the variability of its clinical presentation ranging from mild dyspnea or chest pain to cardiogenic shock and death [1]. We provide an overview of the successful use of an Impella-based strategy for treatment of fulminant myocarditis and cardiogenic shock as a sole means of supporting the circulation, and in combination with ECLS (ECMO plus Impella: ECMELLA), or in combination with RV-Impella RP (BI-PELLA).

Results

Conclusion