Early initiation of mechanical circulatory support and immunomodulation in fulminant myocarditis: a case series of eight patients

Fulminant myocarditis (FM) is a severe and rapidly progressive form of myocarditis, frequently associated with high risk of complications and mortality. Evidence on early initiation of mechanical circulatory support and immunomodulatory therapy is limited.

We aimed to describe the clinical characteristics, management strategies, and outcomes of patients with FM.

We conducted a retrospective study including 8 patients with FM admitted to a tertiary hospital between 2023 and 2025. Demographic, clinical, therapeutic, and outcome data were collected. Categorical variables are presented as frequencies and percentages, and continuous variables as median with interquartile range (IQR).

Among 8 patients (75% female; median age 34.5 years), all presented with a preceding flu-like syndrome (median 5 days). Lymphocytic myocarditis was confirmed in 4 of 5 endomyocardial biopsies. Most patients developed cardiogenic shock (7, 87.5%), with a median shock index of 1.5 [1.3–1.8]. Seven (87.5%) showed biventricular dysfunction and a median left ventricular ejection fraction (LVEF) of 12.5% [10.0–17.5]. Microvoltages were observed in 7 ECGs (87.5%) and myocardial edema in 7 echocardiograms (87.5%). All received corticosteroids and intravenous immunoglobulins; tapering of steroids was maintained in 7 cases. Mechanical circulatory support was required in 87.5% (intra-aortic balloon 62.5%, Impella 37.5%, ECMO 62.5%), initiated early (median 0–1 days after admission). Three patients experienced cardiac arrest and were successfully resuscitated, and one patient died. Median time to LVEF recovery was 8 days, and median hospital stay was 21.5 days.

FM in this series was characterized by early cardiogenic shock and severe biventricular dysfunction. Early initiation of mechanical circulatory support combined with immunomodulatory therapy (corticosteroids and intravenous immunoglobulins) was associated with rapid recovery of left ventricular function in most patients. These findings support the potential benefit of an aggressive early management strategy, although larger studies are needed to confirm the prognostic impact of each intervention.

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