key: cord-0798197-efng3aqb authors: Buitrago, Daniel H.; Munoz, Jennifer; Finkelstein, Emily R.; Mulinari, Leonardo title: A case of fulminant myocarditis due to COVID‐19 in an adolescent patient successfully treated with venous arterial ECMO as a bridge to recovery date: 2022-02-13 journal: J Card Surg DOI: 10.1111/jocs.16313 sha: 57dee70948bee1d686bc3181d6fc07f72764a3c7 doc_id: 798197 cord_uid: efng3aqb Emerging data suggest an association between severe acute respiratory syndrome coronavirus 2 and the development of acute myocarditis, with children and older adults being most at risk. We describe the clinical course of a previously healthy 12‐year‐old female who rapidly deteriorated into cardiogenic shock and arrest due to coronavirus disease 2019 induced fulminant myocarditis, necessitating venous‐arterial extracorporeal membrane oxygenation as a bridge to full recovery. This case highlights the importance of early clinical recognition of myocardial involvement, and the benefits of taking a multidisciplinary approach in treating these patients. Informed consent was obtained from the patient and their guardian for this case report. The patient is a 12-year-old previously healthy female who presented to the emergency department with two days of headache, neck pain, nausea, diarrhea, and overall lethargy. Upon examination, she was found to be febrile, tachycardic, and hypotensive, leading providers to administer 20 ml/kg bolus of 0.9% normal saline. Following this administration of saline, the patient experienced oxygen desaturations into the high 80's and low 90's. Labs were remarkable for elevated aspartate aminotransferase (371 U/L), C-reactive protein (1.6 mg/dL), and troponin (59.6 ng/ml). Chest X-ray (CXR) revealed pulmonary edema and a normal cardiac silhouette ( Figure 1A ). Electrocardiogram (ECG) was significant for ST-segment elevations in the inferior leads, II, III, and AVF ( Figure 1B ). Images from a transthoracic echocardiogram (TTE) demonstrated reduced left ventricular systolic function with normal right ventricular dimensions and systolic function. These constellations were highly suspicious for acute myocarditis, which led to patient admission into the cardiac intensive care unit (CICU) for further management. At this time, the patient's care team decided that she would benefit from VA ECMO as temporary mechanical circulatory support. To the best of our knowledge, this is the first report of COVID-19 induced acute fulminant myocarditis presenting as early cardiogenic shock in a 12-year-old female, successfully treated with VA ECMO as a bridge to full recovery. Our hospital serves as one of the main ECMO referral centers in southern Florida, allowing us to have the capability and resources to offer heroic interventions such as the one presented in this case. Although the exact mechanisms behind acute myocarditis due to COVID-19 are still under investigation, infection is reported to be both a strong and significant risk factor in the development of myocarditis. 3 Among all persons with a diagnosis of acute myocarditis linked to COVID-19, it is likely that a handful represents cases of multisystem inflammatory syndrome (MIS), particularly in children less than 16 years of age. 13, 14 Since the implementation of the mRNA COVID-19 vaccines in December of 2020, studies report an elevated risk of myocarditis among vaccine recipients, predominantly in males aged 12-29 years. 15, 16 However, the COVID-19 infection itself is found to pose a greater risk for myocarditis, with the benefits of vaccination deemed to outweigh this possible risk. 15, 16 Experts currently believe the pathophysiology behind COVID-19 induced acute myocarditis is likely similar to that of other viruses. 3, 17 The proposed mechanisms of direct myocardial injury inflicted by COVID-19 include (i) acute myocarditis defined by an amplified lymphocytic immune response (as observed in our case) and (ii) direct viral damage putatively mediated by activated macrophages. 18, 19 The acute presentation observed in this case report highly suggests a mechanism of direct viral injury to the myocardium, triggering an exaggerated innate immune response. A diagnosis of cardiogenic shock carries a high risk of mortality, especially without definitive intervention. 20 The specific role of ECMO support for patients with cardiopulmonary failure due to COVID-19 infection is continuously evolving. 2 The authors declare no conflict of interest. IRB approval, clinical trial statement, and registration details are N/A. 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Clinical picture and risk prediction of short-term mortality in cardiogenic shock Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock ORCID Emily R. Finkelstein http://orcid.org/0000-0003-4666-0912Leonardo Mulinari http://orcid.org/0000-0001-7138-9912