title: Rapid onset of fulminant myocarditis portends a favourable prognosis and the ability to bridge mechanical circulatory support to recovery.
abstract: OBJECTIVE
  Fulminant myocarditis with cardiogenic shock is fatal without mechanical circulatory support. Once haemodynamic stability has been established with a ventricular assist device (VAD), the decision to wait for myocardial recovery as opposed to listing for an orthotopic heart transplant (OHT) can be difficult. We have undertaken this study to establish the criteria for determining the need for heart transplantation following VAD implant for fulminant myocarditis.
  
  
  METHODS
  A total of 442 VADs were implanted between 1993 and 2011. Twenty-four VADs were implanted for fulminant myocarditis with refractory cardiogenic shock. We retrospectively analysed the variables and the pathology for this cohort. Patients who had a full recovery of myocardial function and subsequent VAD explant (Explant) were compared with those bridged to OHT. There was one acute death.
  
  
  RESULTS
  There was no difference in the past medical history between the groups. Explant patients had a more acute onset of heart failure with a median of 7 days between the onset of symptoms and VAD implant, when compared with 22 days for OHT (P = 0.01). A rapid recovery in myocardial function was seen in the Explant group, with recovery of myocardial function (ejection fraction = 53 ± 24%) in 14 ± 7 days. Myocardial function was sustained for 5 years following the VAD explant. The female gender favoured myocardial recovery and VAD explantability. Two patients had giant cell myocarditis, neither of whom had a recovery of function, and they were bridged to heart transplant with a VAD.
  
  
  CONCLUSIONS
  Fulminant myocarditis is a fatal condition without mechanical support. The rapid onset of symptoms is associated with a complete recovery of myocardial function and VAD explant. The absence of rapid recovery of myocardial function should prompt listing for a heart transplant.
authors.affiliation: Division of Cardiovascular Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
authors.forename: Pavan
authors.initials: P
authors.lastname: Atluri
authors.forename: Brant W
authors.initials: BW
authors.lastname: Ullery
authors.forename: John W
authors.initials: JW
authors.lastname: MacArthur
authors.forename: Andrew B
authors.initials: AB
authors.lastname: Goldstone
authors.forename: Alex S
authors.initials: AS
authors.lastname: Fairman
authors.forename: William
authors.initials: W
authors.lastname: Hiesinger
authors.forename: Michael A
authors.initials: MA
authors.lastname: Acker
authors.forename: Y Joseph
authors.initials: YJ
authors.lastname: Woo
mesh_terms: D000328:Adult; D005260:Female; D016027:Heart Transplantation; D006353:Heart-Assist Devices; D006801:Humans; D008297:Male; D008875:Middle Aged; D009205:Myocarditis / Q000150:complications / Q000628:therapy*; D011446:Prospective Studies; D019919:Prosthesis Implantation / Q000379:methods; D020127:Recovery of Function; D012189:Retrospective Studies; D012770:Shock, Cardiogenic / Q000150:complications / Q000628:therapy*; D016896:Treatment Outcome