Role of extracorporeal membrane oxygenation in the management of myocarditis during caesarean birth.

We describe a pregnant patient who presented in labour with diffuse ST-segment elevation on electrocardiography and biochemical evidence of myocardial injury. Transthoracic echocardiography showed severe biventricular dysfunction. An urgent caesarean birth was indicated due to breech presentation and severe cardiac dysfunction. Intra-operatively, the ventricular function worsened requiring escalating vasopressor administration and the patient developed refractory monomorphic ventricular tachycardia. After delivery, she progressed to cardiogenic shock and required urgent veno-arterial extracorporeal membrane oxygenation cannulation with subsequent axillary Impella 5.5 (Abiomed, Johnson & Johnson MedTech; Danvers, MA, USA) placement for left ventricular unloading. She received immunosuppressive therapy for suspected fulminant myocarditis. Her haemodynamics improved and ventricular function normalised over 12 days of extracorporeal membrane oxygenation support. She was weaned from mechanical circulatory support, her trachea was extubated and an implantable cardioverter-defibrillator was placed. She was discharged home neurologically intact with complete biventricular recovery. The case emphasises the importance of early recognition of rapid haemodynamic decline and timely initiation of mechanical circulatory support in an acute setting.