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J Thorac Cardiovasc Surg 2007;133:1123-1124
© 2007 The American Association for Thoracic Surgery

Letter to the Editor

Reply to the Editor

Surgical Director Cardiac Transplantation, Director Artificial Heart and VAD Program, Lankenau Hospital, Wynnewood, Pa

We thank Dr Khabbaz and colleagues for their contribution to the management of acute necrotizing eosinophilic myocarditis with mechanical circulatory assist. In our article,¹ we make no attempt to suggest that ventricular assist device (VAD) support is the only method by which to properly manage the disease. On the contrary, we recognize the fact that this is a life-threatening disorder on the one hand, but responsive to steroid therapy on the other. Treatment strategies have ranged from steroid therapy alone² to transplantation.³ The main message in our article and others is to support the circulation while the diagnosis is made and treatment is initiated. The precise method by which to accomplish these ends varies according to the condition of the patient at the time of presentation, the tools and technologies available at the treating institution, and the response to steroids. Not every case will be diagnosed antemortem, and not every pathology will respond favorably to steroids. Thus, treatment must take into consideration the possibility that bridge to recovery or bridge to transplant is conceivable. VAD support, therefore, is an excellent tool to accomplish the goal—particularly with a VAD that has features such as short- or long-term support, bridge to recovery or transplant, ambulation with possibility for home discharge, and so forth. In addition, a VAD that has left ventricular (LV) apical cannulation allows for optimal unloading of the LV while on support, antegrade flow pattern, and pulsatile flow. Although extracorporeal life support (ECLS) has been used extensively for acute circulatory decompensation, the femoral–femoral circulation is suboptimal in terms of resting the LV and counterproductive when the LV recovers and weaning is attempted—there is conflicting flow from the heart antegrade and femoral flow retrograde. Furthermore, extracorporeal membrane oxygenation introduces an oxygenator, which is appropriate when lung injury is associated with the heart condition but potentially detrimental when it is not. In addition, femoral cannulation is associated with the potential for vascular complications (both venous and arterial), prevents movement of the patient in the bed or at the bedside, and limits flow by the relatively small size of the cannulae. These views were shared by other surgeons in a discussion of acute heart failure with various types of mechanical circulatory assist technologies.⁴

We congratulate Dr Khabbaz and his team for their wonderful success and encourage others to think about mechanical circulatory support when confronted with a severe case of acute necrotizing eosinophilic myocarditis. The use of ECLS is not an unreasonable method to rapidly restore circulatory stability. However, in the event that ECLS is insufficient, then a more advanced form of mechanical circulatory support, such as a VAD, is appropriate.

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, et al. Acute necrotizing eosinophilic myocarditis successfully treated by high dose methylprednisolone. Jpn Circ J 2001;65:923-926.[Medline]
   
3. Touze JE, Debonne JM, Scheiner C, et al. Acute necrotizing eosinophilic myocarditis. Favorable clinical course after heart transplantation. (In French.) Presse Med 1992;21:565-568.[Medline]
   
4. Discussion of acute heart failure. Moderator: D. Glenn Pennington. Panelists: Michael A. Acker, Jack J. Curtis, Francis D. Pagani, et al. Ann Thorac Surg 2001;71:S82-S85.[Free Full Text]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Louis Samuels Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Samuels, L. Search for Related Content PubMed Articles by Samuels, L. Related Collections Related Article