BACKGROUND: Temporary mechanical circulatory support (t-MCS) is increasingly used in fulminant myocarditis (FM), yet long-term outcomes and risk factors remain poorly defined. METHODS: From the FULLMOON international cohort (419 adults with suspected FM across 36 centers in 15 countries), 295 patients treated with venoarterial extracorporeal membrane oxygenation (V-A ECMO) and/or Impella were analyzed. The primary endpoint was mortality at 1 year, heart transplantation (HTx), or left-ventricular assist device (LVAD). Multivariate Cox regression identified predictors of adverse outcomes. A propensity score-weighted analysis assessed outcomes based on timing of endomyocardial biopsy (EMB): early (≤ 2 days), delayed (> 2 days), or none. RESULTS: The median age was 39 years (IQR 28-60), and 55% were female. Myocarditis was confirmed in 204 (69%) of the patients via histology or cardiac MRI. Histological data were available for 151 (51%) of the cohort. One-year mortality was 36%, while 44% died or had an HTx or LVAD. Predictors of worse outcomes were giant cell myocarditis, older age, cardiac arrest at ECMO initiation, and delayed EMB. Delayed EMB was consistently associated with higher mortality, HTx, or LVAD compared to early (HR = 1.55; 95% CI 1.23-1.96; p < 0.01) or no EMB (HR = 1.59; 95% CI 1.26-2.01; p < 0.01). However, event-free survival did not differ significantly between early EMB and no EMB (HR = 1.03; 95% CI 0.80-1.32; p = 0.85). CONCLUSIONS: Despite a relatively young cohort, FM requiring t-MCS is associated with a high 1-year mortality rate. Timely recognition and early referral to specialized ECMO centers before cardiac arrest are critical.

ACTION Study Group Department of Cardiology Sorbonne Université Assistance Publique Hôpitaux de Paris Pitié Salpêtrière Hospital Paris France

Acute Cardiac Care Unit Department of Cardiology Hospital Marqués de Valdecilla Santander Spain

Acute Cardiovascular Care Unit Cardiology Hospital Germans Trias i Pujol Departament de Medicina Universitat Autònoma de Barcelona Barcelona Spain

Adult Intensive Care Unit Queen Mary Hospital Hong Kong China

Advanced Heart Failure and Transplant Unit Department of Cardiology Hospital Universitario Puerta de Hierro Madrid Spain

Cardiology Department Complejo Hospitalario Universitario de A Coruña CIBERCV A Coruña Spain

Cardiology Department George Pompidou Hospital Assistance Publique Hôpitaux de Paris Paris France

Cardiovascular and Respiratory Physiology TechMed Center University of Twente Enschede The Netherlands

Columbia University College of Physicians and Surgeons New York Presbyterian Hospital and Center for Acute Respiratory Failure Columbia University Medical Center New York USA

Critical Care Medicine Unit the University of Hong Kong Hong Kong China

De Gasperis Cardio Center and Transplant Center Niguarda Hospital Milan Italy

Departement of Intensive Care Unit Pontchaillou Hospital Rennes France

Department of Anaesthesiology and Intensive Care General University Hospital Prague Czech Republic

Department of Anesthesia Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Harvard Medical School Boston USA

Department of Anesthesiology and Critical Care CHU Rouen Rouen France

Department of Cardiology Clínica Las Condes Las Condes Chile

Department of Cardiology Columbia University Irving Medical Center New York Presbyterian Hospital New York USA

Department of Cardiology Hospital Clínic Barcelona Barcelona Spain

Department of Cardiology Hospital Universitario de Canarias Nuestra Señora de Candelaria Tenerife Canary Islands Spain

Department of Cardiology Hospital Universitario La Paz IDIPAZ Madrid Spain

Department of Cardiology Rangueil University Hospital Toulouse France

Department of Emergency and Critical Care Medicine Graduate School of Biomedical and Health Sciences Hiroshima University Hiroshima Japan

Department of Intensive Care Adults and Department of Cardiology Erasmus Medical Center Rotterdam The Netherlands

Department of Intensive Care Medicine and Infectious Diseases Bichat Claude Bernard Hospital Sorbonne Université Assistance Publique Hôpitaux de Paris Paris France

Department of Intensive Care St Vincent Hospital Sydney Australia

Department of Thoracic and Cardiovascular Surgery Korea University Anam Hospital Seoul South Korea

ICAN Intelligence and Omics Institute of Cardiometabolism and Nutrition Pitié Salpêtrière Hospital Paris France

Intensive Cardiac Care Unit Cardiology Department Bellvitge University Hospital Bioheart Grup de Malalties Cardiovasculars Institut d'Investigació Biomèdica de Bellvitge IDIBELL L'Hospitalet de Llobregat Barcelona Spain

Intensive Cardiac Care Unit Department of Cardiology Hospital de la Santa Creu i Sant Pau IIB Sant Pau CIBER CV Universitat Autònoma de Barcelona Barcelona Spain

Intensive Care Center University Medical Center Utrecht Utrecht the Netherlands

Intensive Care Department Hospital Alvaro Cunqueiro Vigo Spain

Intensive Care Medicine Department São João University Hospital Porto Portugal

Intensive Care Unit Alfred Hospital Melbourne Australia

Intensive Care Unit Erasme Hospital Brussels Belgium

Intensive Care Unit Guy's and St Thomas' NHS Foundation Trust Hospital London UK

Intensive Care Unit Hallym University Sacred Heart Hospital Anyang South Korea

Intensive Care Unit Jean Minjoz Hospital Besançon France

Intensive Care Unit University Medical Centre Regensburg Regensburg Germany

Médecine Intensive Réanimation CHU de Lille; Inserm U1285 Univ Lille CNRS UMR 8576 UGSF Unité de Glycobiologie Structurale et Fonctionnelle Lille France

Medical Intensive Care Unit Mondor Hospital Assistance Publique Hôpitaux de Paris Créteil France

Medical Intensive Care Unit Pitié Salpêtrière Hospital Assistance Publique Hôpitaux de Paris Paris France

Medical Surgical Intensive Care Unit Service de Réanimation and Soins Intensifs Polyvalents Félix Guyon Hospital CHU de La Réunion CH de Saintes France

Service de Chirurgie Cardiaque Assistance Publique Hôpitaux de Paris Hôpital Pitié Salpétrière Paris France

Service de Médecine Intensive et Réanimation Inserm U1116 Université de Lorraine CHRU de NANCY Nancy France

Sorbonne Université INSERM UMRS_1166 iCAN Institute of Cardiometabolism and Nutrition Paris France

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