Fulminant myocarditis following SARS-CoV-2 mRNA vaccination rescued with venoarterial ECMO: A report of two cases

Abstract

Introduction: Cases of myocarditis after COVID-19 messenger RNA (mRNA) vaccines administration have been reported. Although the majority follow a mild course, fulminant presentations may occur. In these cases, cardiopulmonary support with venoarterial extracorporeal membrane oxygenation (V-A ECMO) may be needed.

Results: We present two cases supported with V-A ECMO for refractory cardiogenic shock due to myocarditis secondary to a mRNA SARS-CoV2 vaccine. One of the cases was admitted for out-of-hospital cardiac arrest. In both, a peripheral V-A ECMO was implanted in the cath lab using the Seldinger technique. An intra-aortic balloon pump was needed in one case for left ventricle unloading. Support could be successfully withdrawn in a mean of five days. No major bleeding or thrombosis complications occurred. Whereas an endomyocardial biopsy was performed in both, a definite microscopic diagnosis just could be reached in one of them. Treatment was the same, using 1000mg of methylprednisolone/day for three days. A cardiac magnetic resonance was performed ten days after admission, showing a significant improvement of the left ventricular ejection fraction and diffuse oedema and subepicardial contrast intake in different segments. Both cases were discharged fully recovered, with CPC 1.

Conclusions: COVID-19 vaccine-associated fulminant myocarditis has a high morbidity and mortality but presents a high potential for recovery. V-A ECMO should be established in cases with refractory cardiogenic shock during the acute phase.

Keywords: COVID-19 vaccine; Cardiogenic shock; SARS-CoV2; fulminant myocarditis; mRNA vaccine; mechanical support; venoarterial ECMO.

Figure 1.

Late gadolinium enhancement images in a mid-short axis (A) and 4-chamber view (B) showing subepicardial antero-lateral and infero-lateral enhancements from base to apex, suggestive of myocarditis (arrows). There were no signs of acute pericarditis.

Figure 2.

Endomyocardial biopsy tissue shows several inflammatory infiltrates of eosinophils and lymphocytes.

Figure 3.

(a) Short tau inversion recovery (STIR) image in an apical short-axis with signal increase in the anterior segment (arrows). (b) Late gadolinium enhancement image in a 2-chamber view showing subepicardial basal anterior enhancement (arrows).