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J Thorac Cardiovasc Surg 2007;133:1122-1123
© 2007 The American Association for Thoracic Surgery

Letter to the Editor

Extracorporeal life support: An effective and noninvasive way to treat acute necrotizing eosinophilic myocarditis

Ziad Khabbaz, MD, Jean-Michel Grinda, MD, Jean-Noël Fabiani, MD

The Université René Descartes, AP-HP, Service de Chirurgie Cardio-Vasculaire, Hôpital Européen Georges Pompidou, Paris, France

To the Editor:

We read with great interest the case report of Kohout and colleagues1Go describing the successful management of acute necrotizing eosinophilic myocarditis (ANEM) with a biventricular assist device (BIVAD) and steroids.

ANEM is indeed a dramatic condition often leading to a fatal issue unless promptly managed with circulatory support and steroid administration.2Go Endomyocardial biopsy is essential to diagnosis confirmation and rapid therapeutic choice making.

The particularity of ANEM is rapid and spectacular circulatory improvement when steroids are administered early enough.2Go Therefore, we think that a BIVAD is probably too aggressive and that a far less-invasive mean, such as extracorporeal life support (ECLS), is more appropriate for such a condition.

One month ago, we had a case similar to that described by Kohout and colleagues.1Go A 19-year-old woman presented to our department with abrupt onset of congestive heart failure and respiratory distress. She had been already intubated before admission, and echocardiography showed a much altered heart function, with moderately dilated left and right ventricles, and a left ventricular ejection fraction of less then 10%. Computed tomography scan ruled out pulmonary embolism and confirmed severe pulmonary edema. The girl had an unremarkable medical history, with no proof of drug abuse or medications. She had no other symptoms suggesting a preexisting disorder except for mild abdominal pain 1 day earlier. Blood examination results showed no particularity. Serologic and polymerase chain reaction screening results for viral or other infectious diseases returned to normal later on.

In this context of severe congestive heart failure, a femoro-femoral ECLS was instituted in the special care unit at the patient’s bedside, with a blood output of 3.5 L/mn. Inotropic support with norepinephrine and dobutamine was also started. Adequate unloading of the left and right-sided heart chambers was assessed with a Swan–Ganz catheter and echocardiography.

On day 1, chest radiography showed a great reduction of the pulmonary edema (Figure 1). An endomyocardial biopsy was performed, which confirmed the diagnosis of ANEM on day 2. Steroids were immediately begun. The improvement was spectacular. As soon as day 6, echocardiography showed marked improvement of the cardiac function. Weaning from ECLS was begun on day 7 and removed on day 10. Cardiac echocardiography showed a completely normalized left ventricular function. The patient was discharged from the special care unit on day 13.


Figure 1
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  		Figure 1. Chest x-ray film before ECLS (left). It was done on the admission of the patient and shows bilateral pulmonary edema and heart enlargement, with a cardiothoracic index of 0.60. Chest x-ray film 1 day after ECLS institution (right). Pulmonary edema is already greatly reduced, and cardiothoracic index decreased to 0.45.

 
When ANEM is suspected, we think that ECLS is an excellent device for first-line circulatory support. Prompt endomyocardial biopsy is mandatory to confirm the diagnosis and initiate intravenous steroids. This offers the advantage of avoiding the primary use of a far more aggressive mean of circulatory support, such as a BIVAD, in a condition that is likely to respond rapidly and favorably to steroids. In case the biopsy rules out ANEM, then ECLS, if insufficient, could be removed, and other more aggressive means of circulatory support instituted.3Go

References

  1. Kohout J, Ferdinand FD, Imaizumi S, Holmes EC, Samuels LE. A rare case of acute necrotizing eosinophilic myocarditis: bridge to recovery with ventricular assist device support. J Thorac Cardiovasc Surg 2006;132:965-966.[Free Full Text]
  2. Watanabe N, Nakagawa S, Fukunaga T, Fukuoka S, Hatakeyama K, Hayashi T. Acute necrotizing eosinophilic myocarditis successfully treated by high dose methylprednisolone. Jpn Circ J 2001;65:923-926.[Medline]
  3. Cooper LT, Zehr KJ. Biventricular assist device placement and immunosuppression as therapy for necrotizing eosinophilic myocarditis. Nat Clin Pract Cardiovasc Med 2005;2:544-548.[Medline]

Related Article

Reply to the Editor
Louis Samuels
J. Thorac. Cardiovasc. Surg. 2007 133: 1123-1124. [Extract] [Full Text] [PDF]




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