Optimal timing of mechanical circulatory support in rapidly progressive fulminant myocarditis: a case report.

Background: Fulminant myocarditis (FM) can rapidly progress to cardiogenic shock and cardiac arrest; however, the optimal timing of mechanical circulatory support (MCS) initiation remains uncertain, particularly regarding patients with rapidly progressive disease at risk of sudden haemodynamic deterioration. Case summary: A 57-year-old Asian man presented with chest pain following flu-like symptoms. On admission, he was hypotensive with elevated cardiac biomarkers and global left ventricular hypokinesia with a left ventricular ejection fraction of approximately 40%. Acute coronary syndrome was excluded by emergent coronary angiography. During evaluation in the cardiac catheterization laboratory, sustained ventricular tachycardia, rapidly worsening haemodynamic, and early signs of end-organ hypoperfusion indicated progressive cardiogenic shock with a high risk of further deterioration. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was therefore initiated based on these evolving clinical findings. Despite initial stabilization, the patient developed complete atrioventricular block followed by pulseless electrical activity, resulting in cardiac arrest within approximately 4 h of presentation. Combined support with VA-ECMO and Impella CP was established. Cardiac function gradually recovered, and the patient was successfully weaned from MCS. Endomyocardial biopsy confirmed lymphocytic myocarditis. Discussion: This case highlights the clinical importance of determining the optimal timing of MCS initiation in patients with suspected FM at high risk of rapid deterioration. Early support prior to further haemodynamic deterioration may stabilize circulation, facilitate diagnostic procedures, and provide a bridge to myocardial recovery.