Successful VA-ECMO rescue of life-threatening cardiotoxicity following paclitaxel and cisplatin neoadjuvant chemotherapy for laryngeal cancer: a case report.

backgroundNeoadjuvant chemotherapy with paclitaxel and cisplatin (TP regimen) is a cornerstone of treatment for locally advanced laryngeal squamous cell carcinoma. While effective, this regimen can, in rare instances, induce multiple adverse events, including a life-threatening fulminant myocarditis. Characterized by sudden and severe cardiac inflammation leading to cardiogenic shock and arrhythmias, this complication carries a high mortality rate. Its non-specific initial symptoms often mimic more common conditions like acute coronary syndrome, posing significant diagnostic and therapeutic challenges for oncologists and critical care teams. CASE PRESENTATION: We describe the case of a 59-year-old male with laryngeal cancer who, after completing three cycles of neoadjuvant TP chemotherapy and undergoing a total laryngectomy, presented with acute-onset dyspnea and chest pain. His condition rapidly deteriorated into profound cardiogenic shock, characterized by severe hypotension refractory to maximal vasopressor support, and a third-degree atrioventricular block necessitating temporary cardiac pacing. Diagnostic investigations revealed a severely depressed left ventricular ejection fraction (< 30%) with global hypokinesis on echocardiography and exceptionally high serum high-sensitivity troponin I levels (> 27 ng/mL). The patient developed multi-organ failure, including acute kidney and liver injury requiring continuous renal replacement therapy. After emergent coronary angiography ruled out obstructive coronary artery disease and extensive microbiological screenings were negative, a diagnosis of chemotherapy-induced fulminant myocarditis was established. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was promptly initiated to provide biventricular support and restore end-organ perfusion, alongside high-dose corticosteroids and intravenous immunoglobulin. The patient's myocardial function substantially improved over eight days, leading to successful weaning from VA-ECMO. He was subsequently discharged with complete cardiac and renal function recovery.

conclusionThis case describes fulminant myocarditis with cardiogenic shock and high-grade atrioventricular block following neoadjuvant paclitaxel-cisplatin chemotherapy for laryngeal cancer. Early initiation of VA-ECMO, together with intensive supportive care and immunosuppressive therapy, was associated with complete recovery of cardiac and renal function. This case underscores the need to consider severe myocarditis in patients receiving TP chemotherapy who present with acute cardiac symptoms, and illustrates that timely use of VA-ECMO can provide an effective bridge to recovery in selected patients.