Management of fulminant myocarditis: peripheral venoarterial extracorporeal membranous oxygenation and associated complications

Background

Fulminant Myocarditis (FM) leads to cardiogenic shock with multi-organic dysfunction, being peripheral venoarterial extracorporeal membranous oxygenation (VA-ECMO) a rescue technique. Despite growing experience, it is still related with several complications. We aim to appraise the management of patients with FM and the adverse events associated to VA-ECMO.

Methods

We conducted a retrospective study in a ECMO centre in Portugal, which included 15 patients diagnosed with FM and managed on VA-ECMO from 2008 to 2018. Hemorrhage or infection on cardiac device site, cardiac tamponade, limb ischemia, ischemic stroke, cerebral hemorrhage, severe hemolysis and accidental decannulation were considered major complications.

Results

For sample characteristics and resumed complications, see Table. Inotropic and mechanical ventilation support were transversal to all, with only one patient extubated before decannulation. Six patients received renal replacement therapy, whom half recovered renal function and the remaining died. VA-ECMO operated on average for 8,5 days (range, 1 to 20 days). 3 patients had concomitant Impella heart pump and one of them had a third assistance device with Intra-Aortic Ballon pump.

Major complications were observed in 9 patients (60%), being ischemic stroke the most common. Limb ischemia, observed in 5 patients, related with longer duration of VA-ECMO support (limb ischemia vs non-limb ischemia; 12,8±4,9 vs. 6,8±6,5 days). Two patients presented hemorrhage on cardiac assistance device site, and 1 patient had a cardiac tamponade, all with fatal outcome. Infection on cardiac site, cerebral hemorrhage, severe hemolysis and accidental decannulation were not observed.

Conclusion

The most common complications were ischemic stroke and limb ischemia, both not apparently related with mortality. Differently, hemorrhage on cardiac site and cardiac tamponade were less frequent but presented ominous outcome. Overall, adverse events can be serious and hinder recovery and discharge.

Funding Acknowledgement

Type of funding sources: None.

Characterization of residual lignin after SO(2)-catalyzed steam explosion and enzymatic hydrolysis of Eucalyptus viminalis wood chips

The lignin component found in both water insoluble (WI) and water and alkali insoluble (WIA) fractions derived from SO(2)-impregnated steam-exploded eucalyptus chips (SEE) was isolated and characterized. Dioxane lignins with a sugar content lower than 2% (w/w) were obtained after each material was treated with commercial cellulases. The C9 formulas of both SEE-WI and SEE-WIA dioxane lignins were C(9)H(6.83)N(0.04)O(2.24)(OCH(3))(1.21)(OH(aro))(0.56)(OH(ali))(0. 77) and C(9)H(8.65)N(0.29)O(1.97)(OCH(3))(0.90)(OH(aro))(0. 46)(OH(ali))(1.02), respectively. The weight-average molecular weight (M(w)) of the SEE-WI lignin corresponded to 3.85 kDa, whereas the SEE-WIA lignin had an M(w) of 3.66 kDa for the same polydispersity of 2.4. The SEE-WIA lignin was shown to be more thermally stable than the SEE-WI lignin, requiring temperatures in the range of 520 degrees C for complete degradation. FTIR and (1)H NMR analyses of both untreated and peracetylated lignin fractions showed that (a) the alkali insoluble lignin contained a relatively higher degree of substitution in aromatic rings per C9 unit and that (b) alkaline extraction removed lignin fragments containing appreciable amounts of phenolic hydroxyl groups.