Key result
VA-ECMO reverses complete AV block and shock in pediatric fulminant myocarditis after temporary pacing fails.
Why the study?
Bradycardia and high-degree heart block in pediatric fulminant myocarditis significantly increase the risk of cardiogenic shock and mortality, and standard resuscitation protocols often fall short.
Does VA-ECMO improve survival and recovery in pediatric myocarditis-related bradycardia with shock compared to pacing?
Case Report (n=1)
Does VA-ECMO improve survival and recovery in pediatric myocarditis-related bradycardia with shock compared to pacing?
In pediatric fulminant myocarditis with bradycardia and shock, early VA-ECMO provides definitive mechanical support and should be prioritized over pacing.
May support VA-ECMO in refractory pediatric bradycardia; hypothesis-generating and leaves open need for controlled trials.
Background: Fulminant myocarditis is a life-threatening inflammatory condition of the myocardium. While bradycardia and high-degree heart block occur in only 1.7% of pediatric cases, their presence significantly increases the risk of cardiogenic shock and mortality. Standard resuscitation protocols often fall short when the underlying pathology involves severe ventricular dysfunction and electrical instability. Clinical Course: A 14-year-old boy presented with vomiting, chest pain, and syncope in recent two days. Initial evaluation revealed: Heart Rate: 53 bpm (Bradycardia); EKG: Complete AV Block (CAVB); Biomarkers: Troponin-T (5,266 ng/L) and elevated lactate (6.7 mg/dL); Echocardiography: global LV hypokinesia with ejection fraction of 39%. Despite a temporary pacemaker and IVIG, he deteriorated into pulseless bradycardia. Upon transfer, VA-ECMO was established during CPR. Post-ECMO, lactate levels normalized rapidly (14.81 to 3.87 mg/dL), and rhythm converted to accelerated junctional rhythm. The patient was successfully weaned from ECMO on day 5 and discharged on day 17 with excellent neurological recovery. Discussion: The 2025 Pediatric Advanced Life Support (PALS) guidelines suggest transcutaneous pacing (Class 2b) for symptomatic bradycardia; however, myocarditis presents a unique challenge. In an “irritable myocardium,” pacing often fails to improve systemic perfusion because the primary issue is pump failure, not just rate. PALS specifically recommends VA-ECMO or mechanical circulatory support (Class 2a) for refractory low cardiac output in myocarditis to provide end-organ support and prevent cardiac arrest. Conclusion: For pediatric myocarditis-related bradycardia accompanied by shock, VA-ECMO should be prioritized over pacing. Early mechanical support serves as the definitive intervention, successfully reversing CAVB and profound hypoperfusion where traditional electrical pacing may fail.
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Jeng-Hung et al. (2026) conducted a case report in Fulminant myocarditis with bradycardia and complete AV block (n=1). VA-ECMO vs. Temporary pacemaker (transvenous pacing) was evaluated on Survival and neurological recovery. VA-ECMO successfully reversed complete AV block and profound hypoperfusion in a 14-year-old boy with fulminant myocarditis-related bradycardia and shock after temporary pacing failed.
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