Successful management of fulminant myocarditis in an adolescent using early awake VA-ECMO support: a case report

We report the case of a 14-year-old female student who developed fulminant myocarditis (FM) following an upper respiratory infection. She presented with acute chest pain, cardiogenic shock, and recurrent episodes of cardiac arrest. Despite maximal inotropic support, profound hemodynamic instability persisted. Early initiation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) under awake conditions—without endotracheal intubation—achieved immediate circulatory stabilization. This enabled the implementation of a comprehensive, multimodal treatment strategy, including temporary pacing, immunomodulation, and guideline-directed heart failure management. Serial echocardiography demonstrated complete recovery of left ventricular systolic function, with ejection fraction improving from a nadir of 6% to 50%. The patient was successfully weaned from ECMO and discharged with full cardiac recovery. This case underscores that early, proactive deployment of VA-ECMO in hemodynamically unstable fulminant myocarditis is life-saving. Moreover, an “awake ECMO” strategy can be safely implemented in carefully selected patients, offering significant physiological and psychological advantages.