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A Young Woman With Viral Myocarditis

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her mid-20s presented with cardiogenic shock. On presentation, she was afebrile with cool extremities; her blood pressure was 75/51 mm Hg, heart rate was 147 beats per minute, respiratory rate was 20 breaths per minute, and oxygen saturation was 99% on mechanical ventilation. Her chest examination revealed bilateral coarse breath sounds and distant heart sounds. Transthoracic echocardiogram revealed an ejection fraction of 10% with elevated filling pressures and no significant valvular abnormalities. Owing to hemodynamic instability, the patient was given venoarterial extracorporeal membrane oxygenation (ECMO) with the peripheral ventricular assist device (pVAD) Impella CP (Abiomed) and was administered high-dose intravenous corticosteroids. Endomyocardial biopsy showed lymphocytic viral myocarditis. There was significant hemodynamic improvement within 48 hours; transthoracic echocardiogram was obtained and showed impressive recovery of the left ventricular function to an ejection fraction of 45%. As a result, ECMO was decannulated after 72 hours. Left pVAD support was maintained alone for another 24 hours. In the interim, her vitals remained unchanged, but the patient developed hematuria and laboratory parameters suggestive of hemolysis. Chest radiography showed pulmonary edema, and low-flow alarms sounded on the device console. Transthoracic echocardiogram showed severe mitral regurgitation (MR), and a transesophageal echocardiogram was performed to evaluate pVAD positioning (Figure and Video).

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Iatrogenic mitral regurgitation

B. Consult cardiovascular surgery to discuss mitral valve surgery

The key to the correct diagnosis in this patient was the transesophageal echocardiogram revealing a new, severe, eccentric, posteriorly directed jet of MR and flail segment of the A3 anterior aortic leaflet (Figure). Recognition of the pVAD as a potential cause of iatrogenic MR is important, as acute severe MR requires prompt early surgical intervention.

Frequent complications after pVAD placement include thrombus formation, tamponade, right ventricular failure, and hypovolemia. To our knowledge, there have been very few case reports of iatrogenic MR in patients with pVAD.1,2 Possible mechanisms of injury are damage to the mitral valve apparatus during the insertion of pVAD or subsequent migration of the device. In fulminant myocarditis, it is hypothesized that the myocardial tissue is inflamed and friable, making it more susceptible to injury.3 In this patient, the pVAD was placed emergently when the patient was hemodynamically unstable. While receiving ECMO support, the complete hemodynamic effect of MR is usually not apparent owing to the altered physiology. Severe MR and flail leaflet were only apparent after ECMO decannulation.

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Article Information

Published Online: February 23, 2022. doi:10.1001/jamacardio.2021.6010

Correction: This article was corrected on April 13, 2022, to correct the figure legend.

Corresponding Author: Asad J. Torabi, MD, Division of Cardiology, Krannert Institute of Cardiology at Indiana University School of Medicine, 1800 N Capital Ave, Indianapolis, IN 46202 (ajtorabi@iupui.edu).

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank Jeffrey E. Everett, MD, Indiana University School of Medicine, Indianapolis, for his assistance in reviewing and editing the manuscript; he did not receive financial compensation for this contribution.

References
1.
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2.
Khalid  N , Shlofmitz  E , Case  BC , Waksman  R .  Entrapment of the Impella heart pump in the mitral subvalvular apparatus.   EuroIntervention. 2021;16(15):e1262-e1263.PubMedGoogle ScholarCrossref
3.
Yamamoto  M , Yoneyama  F , Kato  H , Ieda  M .  Mitral chordal rupture by Impella 5.0 in a patient with fulminant myocarditis and inflammation of mitral chordae.   Eur Heart J. 2020;41(20):1943. doi:10.1093/eurheartj/ehz675PubMedGoogle ScholarCrossref
4.
Suri  RM , Vanoverschelde  JL , Grigioni  F ,  et al.  Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to flail mitral valve leaflets.   JAMA. 2013;310(6):609-616. doi:10.1001/jama.2013.8643PubMedGoogle ScholarCrossref
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Otto  CM , Nishimura  RA , Bonow  RO ,  et al.  2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.   Circulation. 2021;143(5):e72-e227.PubMedGoogle Scholar
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Sef  D , Kabir  T , Lees  NJ , Stock  U .  Valvular complications following the Impella device implantation.   J Card Surg. 2021;36(3):1062-1066. doi:10.1111/jocs.15303PubMedGoogle ScholarCrossref
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Pivato  CA , Ferrante  G , Briani  M , Sanz Sanchez  J , Reimers  B , Pagnotta  P .  Mitraclip treatment for severe mitral regurgitation due to chordae rupture following Impella CP support in a patient with severe aortic stenosis.   Cardiovasc Revasc Med. 2021;28S:118-120.PubMedGoogle Scholar
8.
Bhatia  N , Richardson  TD , Coffin  ST , Keebler  ME .  Acute mitral regurgitation after removal of an Impella device.   Am J Cardiol. 2017;119(8):1290-1291. doi:10.1016/j.amjcard.2016.12.020PubMedGoogle ScholarCrossref
9.
Eastaugh  LJ , Thiagarajan  RR , Darst  JR , McElhinney  DB , Lock  JE , Marshall  AC .  Percutaneous left atrial decompression in patients supported with extracorporeal membrane oxygenation for cardiac disease.   Pediatr Crit Care Med. 2015;16(1):59-65. doi:10.1097/PCC.0000000000000276PubMedGoogle ScholarCrossref
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