Venoarterial extracorporeal membrane oxygenation for fulminant chemotherapy-induced myocarditis: a case report and literature review

BACKGROUND: Chemotherapy-induced myocarditis (CIM) is a rare but life-threatening complication with limited guidelines regarding venoarterial extracorporeal membrane oxygenation (VA-ECMO) as salvage therapy. CASE REPORT: We present the case of a 32-year-old female with metastatic thymoma who developed fulminant CIM following paclitaxel-based chemotherapy. Despite aggressive multimodal immunosuppressive therapy, she progressed to refractory cardiogenic shock and pulseless ventricular tachycardia, necessitating emergent VA-ECMO. Hemodynamic stability was achieved, and she was successfully decannulated after a period of support with signs of improving cardiac function. However, she suffered a sudden cardiac arrest due to ventricular fibrillation shortly after decannulation. Although return of spontaneous circulation (ROSC) was achieved, life-sustaining therapies were subsequently withdrawn per family's decision in light of the grave prognosis. CONCLUSIONS: This case demonstrates that VA-ECMO can serve as a crucial salvage bridge in fulminant CIM. However, it starkly highlights the precarious nature of recovery. The fatal arrhythmia post-decannulation underscores that the resolution of life-threatening electrical instability may lag significantly behind the recovery of systolic function, a critical learning point for managing such cases. This dissociation, combined with the unique challenges in immunocompromised oncology patients, demands meticulous patient selection, prolonged post-weaning monitoring, and proactive multidisciplinary decision-making.