A 19-year-old woman with no previous cardiac history was admitted to the hospital with third-degree atrioventricular block and left ventricular dysfunction. Her condition quickly deteriorated to severe biventricular failure and cardiogenic shock requiring mechanical circulatory support. An endomyocardial biopsy revealed lymphocytic myocarditis with no PCR-detectable viral genomes, with CD8 T-cell predominance and pro-inflammatory macrophage expansion shown by myocardial flow cytometry. The therapy consisted of immunosuppression (high-dose methylprednisolone) and temporary mechanical circulatory support with enhanced ability to achieve left ventricular unloading by combination of extracorporeal membrane oxygenation with Impella (ECMELLA). After 2 weeks of support, complete and sustained recovery from myocarditis was observed.

Department of Cardiology Institute for Clinical and Experimental Medicine IKEM Videnska 1958 9 140 21 Prague 4 Czech Republic

Department of Pathology Johns Hopkins University Baltimore MD USA

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McCarthy RE 3rd, Boehmer JP, Hruban RH, Hutchins GM, Kasper EK, Hare JM, Baughman KL. Long‐term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis. New Engl J Med 2000; 342: 690–695. PubMed

Caforio AL, Pankuweit S, Arbustini E, Basso C, Gimeno‐Blanes J, Felix SB, Fu M, Helio T, Heymans S, Jahns R, Klingel K, Linhart A, Maisch B, McKenna W, Mogensen J, Pinto YM, Ristic A, Schultheiss HP, Seggewiss H, Tavazzi L, Thiene G, Yilmaz A, Charron P, Elliott PM. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 2013; 34: 2636–2648. PubMed

Tschope C, Van Linthout S, Klein O, Mairinger T, Krackhardt F, Potapov EV, Schmidt G, Burkhoff D, Pieske B, Spillmann F. Mechanical unloading by fulminant myocarditis: LV‐IMPELLA, ECMELLA, BI‐PELLA, and PROPELLA concepts. J Cardiovasc Transl Res 2019; 12: 116–123. PubMed PMC

Ammirati E, Cipriani M, Lilliu M, Sormani P, Varrenti M, Raineri C, Petrella D, Garascia A, Pedrotti P, Roghi A, Bonacina E, Moreo A, Bottiroli M, Gagliardone MP, Mondino M, Ghio S, Totaro R, Turazza FM, Russo CF, Oliva F, Camici PG, Frigerio M. Survival and left ventricular function changes in fulminant versus nonfulminant acute myocarditis. Circulation 2017; 136: 529–545. PubMed

Ammirati E, Veronese G, Brambatti M, Merlo M, Cipriani M, Potena L, Sormani P, Aoki T, Sugimura K, Sawamura A, Okumura T, Pinney S, Hong K, Shah P, Braun O, Van de Heyning CM, Montero S, Petrella D, Huang F, Schmidt M, Raineri C, Lala A, Varrenti M, Foa A, Leone O, Gentile P, Artico J, Agostini V, Patel R, Garascia A, Van Craenenbroeck EM, Hirose K, Isotani A, Murohara T, Arita Y, Sionis A, Fabris E, Hashem S, Garcia‐Hernando V, Oliva F, Greenberg B, Shimokawa H, Sinagra G, Adler ED, Frigerio M, Camici PG. Fulminant versus acute nonfulminant myocarditis in patients with left ventricular systolic dysfunction. J Am Coll Cardiol 2019; 74: 299–311. PubMed

Tschope C, Cooper LT, Torre‐Amione G, Van Linthout S. Management of myocarditis‐related cardiomyopathy in adults. Circ Res 2019; 124: 1568–1583. PubMed

Hou X, Chen G, Bracamonte‐Baran W, Choi HS, Diny NL, Sung J, Hughes D, Won T, Wood MK, Talor MV, Hackam DJ, Klingel K, Davogustto G, Taegtmeyer H, Coppens I, Barin JG, Cihakova D. The cardiac microenvironment instructs divergent monocyte fates and functions in myocarditis. Cell Rep 2019; 28: 172–189. PubMed PMC

Abdel‐Aty H, Boye P, Zagrosek A, Wassmuth R, Kumar A, Messroghli D, Bock P, Dietz R, Friedrich MG, Schulz‐Menger J. Diagnostic performance of cardiovascular magnetic resonance in patients with suspected acute myocarditis: comparison of different approaches. J Am Coll Cardiol 2005; 45: 1815–1822. PubMed

Ginsberg F, Parrillo JE. Fulminant myocarditis. Crit Care Clin 2013; 29: 465–483. PubMed

Donker DW, Brodie D, Henriques JPS, Broome M. Left ventricular unloading during veno‐arterial ECMO: a simulation study. ASAIO J 2019; 65: 11–20. PubMed PMC

Spillmann F, Van Linthout S, Schmidt G, Klein O, Hamdani N, Mairinger T, Krackhardt F, Maroski B, Schlabs T, Soltani S, Anker S, Potapov EV, Burkhoff D, Pieske B, Tschope C. Mode‐of‐action of the PROPELLA concept in fulminant myocarditis. Eur HeartJ 2019; 40: 2164–2169. PubMed PMC