FULMINANT MYOCARDITIS: EARLY DIAGNOSIS AND MECHANICAL CIRCULATORY SUPPORT IN EMERGENCIES
Keywords:
fulminant myocarditis; cardiogenic shock; VA-ECMO; Impella; mechanical circulatory support; endomyocardial biopsy; emergency careAbstract
DOI: https://doi.org/10.46296/gt.v9i18.0398
Abstract
Background: Fulminant myocarditis (FM) is an uncommon form of acute myocardial inflammation that may progress within hours to cardiogenic shock, malignant arrhythmias, and multiorgan failure. Outcome depends on rapid recognition of the high-risk phenotype, exclusion of competing diagnoses, and restoration of perfusion before irreversible end-organ injury. Objective: To synthesize contemporary clinical evidence on early diagnosis, endomyocardial biopsy, cardiac magnetic resonance, and mechanical circulatory support (MCS) strategies for FM in emergency care. Methods: PRISMA 2020 systematic review. A reproducible PubMed/MEDLINE search was conducted from January 2000 through 30 march 2026 using terms related to fulminant myocarditis, biopsy, cardiac magnetic resonance, ECMO, Impella, and mechanical circulatory support. Primary studies enrolling at least five patients and reporting diagnostic, survival, ventricular recovery, weaning, transplantation, or complication outcomes were prioritized. Because of clinical heterogeneity and overlapping registries, quantitative pooling was not performed. Results: Of 273 identified records, 50 reports underwent eligibility assessment and 32 primary studies were included. Historical VA-ECMO series reported in-hospital survival around 70% in selected populations, whereas contemporary high-acuity cohorts reported in-hospital or 1-year mortality approaching 36–50%. In a multicenter cohort of 217 FM patients receiving VA-ECMO, left ventricular unloading within 24 hours was associated with fewer deaths, cardiac replacement events, or cardiovascular rehospitalizations. The J-PVAD registry included 269 FM patients treated with Impella and reported 30-day survival of 74.3%. FULLMOON data supported early biopsy for etiologic definition and prognostic stratification. Conclusions: FM is a time-dependent cardiovascular emergency. The immediate priority is restoration of perfusion and oxygen delivery, early shock-team activation, and phenotype-guided MCS. Early biopsy is particularly relevant when treatable inflammatory subtypes are suspected. Early LV unloading is increasingly supported when VA-ECMO causes or sustains ventricular overload, but device comparisons remain limited by confounding by indication.
Keywords: fulminant myocarditis; cardiogenic shock; VA-ECMO; Impella; mechanical circulatory support; endomyocardial biopsy; emergency care.
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