Recurrent Necrotizing Myocarditis Treated with Ventricular Assist Device Bridge to Heart Transplantation - A Case Report

• Published in: The Journal of heart and lung transplantation Vol. 41; no. 4; p. S250
• Main Authors: Treffalls, J.A., Shah, A., Griffith, B.P., Feller, E.D.
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01.04.2022
• ISSN: 1053-2498; 1557-3117
• DOI: 10.1016/j.healun.2022.01.1768

Necrotizing myocarditis is a rare disorder characterized by myocyte necrosis, edema, and cardiogenic shock. Recurrence of necrotizing myocarditis is exceedingly rare, and progression can lead to clinically significant conduction abnormalities that portend a poor outcome. The use of a left ventricular assist device (LVAD) can support patients with fulminant myocarditis as a destination therapy or as a bridge to heart transplantation. A 24-year-old male presented to our center in cardiogenic shock following multiple discharges of his implantable cardioverter defibrillator. His history was significant for necrotizing myocarditis, with the initial presentation at age 18. He had recurrence with worsening of cardiac function at age 21, necessitating LVAD implantation. At current presentation he was noted to have recurrent ventricular tachycardia that progressed to near electrical silence during his admission, with only low voltage QRS complexes present (Figure 1). His echocardiogram was also notable for a large left ventricular thrombus with near akinesis of his heart. Despite addition of inotropic support, there were no changes to his electrocardiogram or cardiac contractility. As a result, he was elevated to status 1 for heart transplantation. With optimization of LVAD function, he was able to maintain hemodynamic stability and adequate perfusion of his end-organs despite mild aortic insufficiency. On hospital day 12, he underwent heart transplantation. Notably, the histopathology on explant was consistent with recurrent, fulminant myocarditis. His postoperative course was complicated by severe right ventricular dysfunction and ISHLT Grade 2 acute cellular rejection treated with anti-thymocyte globulin and high dose methylprednisolone. He was discharged home on postoperative day 23. The patient is now eight months out from transplant and at most recent follow-up is doing well without signs of rejection. Here we report a rare and complex case of recurrent necrotizing myocarditis in a 24-year-old male. Presumably, the progression of myocyte necrosis was the cause of this patient's progressive arrythmias, near electrical silence, and akinesis. In this setting, the patient's existing LVAD provided sufficient systemic support, allowing for expedited heart transplantation.