Successful Treatment of Novel H1N1 Influenza related Fulminant Myocarditis with Extracorporeal Life Support

An 18 year old previously fit and well female suffered from lethargy and malaise for six weeks combined with rigors, fever, nausea, vomiting and diarrhea over four days. After collapsing on train, she was admitted to local hospital where she was diagnosed of cardiogenic shock with echocardiogram showing severely impaired left ventricular function with ejection fraction of 20%. She was started on Dobutamine and transferred to our institution for further management. On arrival, the systolic blood pressure was 54 mmHg, sinus tachycardia of 130 per minute, tachypnea and the lactate of 13 mmol/l. The air entry was good and there were no added sounds on auscultation. She arrested shortly after arrival, was intubated and ventilated and after 65 minutes of cardiopulmonary resuscitation (CPR) a Veno - Arterial Extra corporal membrane oxygenator (VA ECMO) was inserted. The decision to put ECMO was based on need of short term circulatory support and emergency situation. The option of short term left ventricular assist device (LVAD) was not feasible as patient was being resuscitated and could not be moved in theatre for LVAD implantation. The left femoral vessels accessed percutaneously by Seldinger technique. A 17 and 21 French cannulae were inserted into Femoral artery and vein respectively and connected to ECMO circuit comprising Levitronic CentriMag pump and Medtronic oxygenator. A 10 French cannula was inserted in Femoral artery for distal limb perfusion and connected to the main arterial cannula by 'Y' connection. Cardiovascular stability could be achieved with initial ECMO flow of 3 l/min and moderate doses of Noradrenalin and Adrenaline targeting a mean arterial pressure of 60 mmHg. Due to the cardiogenic shock and the hypotension caused by the low cardiac output state she developed acute kidney injury and was treated with continuous veno-venous hemofiltration (CVVH). On day 3, she developed compartment syndrome in the leg on the side of ECMO insertion which needed fasc