Stepwise extracorporeal membrane oxygenation conversion strategy with IMPELLA support in giant cell myocarditis complicated by severe hypoxemic respiratory failure due to Mendelson syndrome:A case report

Q: What are the key findings of this study?

Stepwise ECMO reconfiguration (V-A to V-AV to V-V) with IMPELLA resolved differential hypoxia and improved LVEF from 5% to 45%, enabling weaning by day 10.

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Fulminant giant cell myocarditis complicated by cardiogenic shock and severe hypoxemic respiratory failure due to Mendelson syndrome (n=1). Intervention: Stepwise ECMO conversion strategy (V-A to V-AV to V-V ECMO) with IMPELLA support (ECPELLA). Primary outcome: Weaning from extracorporeal support and recovery of cardiopulmonary function.

Q: What does this research mean for the field?

Stepwise ECMO reconfiguration from V-A to V-AV and subsequently to V-V combined with IMPELLA support resolves differential hypoxia and supports recovery in patients with concomitant cardiogenic shock and severe hypoxemic respiratory failure. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Masaki Terazawa; Saki Saijo; Hitoshi Chikami; Kota Miyoshi; Konomi Moriwaki; Shotaro Otani; Kazuki Momota; Hiroki Sato; Yusuke Akimoto; Toshiyuki Nunomura; Manabu Ishihara; Taiga Itagaki; Jun Oto

doi:10.2152/jmi.73.561

January 1, 2026The Journal of Medical InvestigationOpen Access

Stepwise extracorporeal membrane oxygenation conversion strategy with IMPELLA support in giant cell myocarditis complicated by severe hypoxemic respiratory failure due to Mendelson syndrome:A case report

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Key result

Stepwise ECMO reconfiguration with Impella resolves differential hypoxia and improves LVEF by ~40 points.

n=1

Why the study?

Fulminant giant cell myocarditis is a rare, rapidly progressive condition often requiring mechanical circulatory support, and its management is particularly challenging when complicated by severe respiratory failure requiring simultaneous optimization of circulatory and respiratory support.

Key Points

To describe a stepwise reconfiguration strategy of extracorporeal membrane oxygenation combined with IMPELLA support for managing discordant cardiac and pulmonary recovery in fulminant giant cell myocarditis complicated by Mendelson syndrome.
Case report of a 66-year-old man presenting with sustained ventricular tachycardia, cardiogenic shock, and massive aspiration during cardiopulmonary resuscitation resulting in Mendelson syndrome.
Mechanical circulatory and respiratory support was initiated with veno-arterial (V-A) ECMO plus IMPELLA CP (ECPELLA) and managed with lung-protective ventilation and bronchoscopic suctioning.
Extracorporeal configurations were sequentially adapted across the clinical course from V-A ECMO to veno-arterial-venous (V-AV) ECMO on day 2, veno-venous (V-V) ECMO with IMPELLA on day 7, and V-V ECMO alone on day 9.
Conversion from V-A to V-AV ECMO corrected differential hypoxia manifested by a right radial SpO2 of 91% and PaO2 of 55.6 mmHg despite preserved systemic perfusion.
Left ventricular ejection fraction improved from approximately 5% on day 0 to approximately 40% on day 7 with lactate <2.0 mmol/L, enabling transition to V-V ECMO.
Static lung compliance improved from approximately 1 mL/cmH2O at admission to approximately 35 mL/cmH2O on day 10, facilitating successful decannulation from V-V ECMO and subsequent extubation on day 16.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

1 male patient (age 66) with fulminant giant cell myocarditis, cardiogenic shock, and severe aspiration-induced hypoxemic respiratory failure (Mendelson syndrome), followed until hospital day 49.

I

Intervention

Stepwise extracorporeal membrane oxygenation (ECMO) conversion strategy with percutaneous left ventricular assist device (IMPELLA CP) support (ECPELLA): initiated as veno-arterial (V-A) ECMO plus IMPELLA on day 0, converted to veno-arterial-venous (V-AV) ECMO with IMPELLA on day 2 due to differential hypoxia, transitioned to veno-venous (V-V) ECMO with IMPELLA on day 7 following partial cardiac recovery, simplified to V-V ECMO alone on day 9 after IMPELLA removal, and discontinued on day 10. Concomitant therapies included dobutamine (up to 5 µg/kg/min), noradrenaline (up to 0.3 µg/kg/min), lung-protective mechanical ventilation, daily bronchoscopic suctioning, and empirical ampicillin/sulbactam for 7 days (no immunosuppressive therapy was administered).

O

Outcome

Resolution of differential hypoxia, cardiac and pulmonary recovery (LVEF and static lung compliance), successful weaning from extracorporeal support and mechanical ventilation, and survival.hard clinical

In a patient with fulminant giant cell myocarditis complicated by severe hypoxemic respiratory failure from Mendelson syndrome, a physiology-driven stepwise ECMO conversion strategy (V-A to V-AV to V-V ECMO) with IMPELLA support successfully resolved differential hypoxia and bridged the patient to cardiopulmonary recovery.

Limitations

Single-patient case report
Coexistence of fulminant giant cell myocarditis and Mendelson syndrome and the exact sequence of ECMO reconfiguration are case-specific
Immunosuppressive therapy was not administered due to delayed histological confirmation and prior spontaneous clinical improvement
Patient ultimately died on day 49 from recurrent aspiration leading to airway obstruction and asphyxia after ICU discharge
Single patient case report
The coexistence of fulminant giant cell myocarditis and Mendelson syndrome and the exact sequence of ECMO reconfiguration are case-specific
Immunosuppressive therapy was deferred and ultimately not administered because clinical improvement occurred before histological confirmation

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Implication

Supports stepwise ECMO reconfiguration with Impella for differential hypoxia in combined shock and respiratory failure; hypothesis-generating, requires prospective validation.

Abstract

Background:Fulminant giant cell myocarditis (GCM) is a rare, rapidly progressive condition that often requires mechanical circulatory support. Management becomes particularly challenging when complicated by severe respiratory failure, necessitating the simultaneous optimization of circulatory and respiratory support. Case presentation:A 66-year-old man presented with sustained ventricular tachycardia and cardiogenic shock, requiring veno-arterial extracorporeal membrane oxygenation (V-A ECMO) with IMPELLA support (ECPELLA). During cardiopulmonary resuscitation, massive aspiration occurred, resulting in severe hypoxemic respiratory failure consistent with Mendelson syndrome. As the cardiac function partially recovered, differential hypoxia developed under V-A ECMO, characterized by inadequate upper-body oxygenation despite preserved systemic perfusion. The ECMO configuration was converted to veno-arterial-venous (V-AV) ECMO, leading to a marked improvement in oxygenation. With further cardiac recovery and persistent respiratory failure, support was transitioned to veno-venous (V-V) ECMO. The patient was successfully weaned from extracorporeal support and mechanical ventilation. Conclusion:This case highlights the importance of recognizing differential hypoxia and implementing stepwise ECMO reconfiguration based on the evolving cardiopulmonary physiology. A flexible, physiology-driven approach may be crucial for optimizing oxygen delivery in patients with combined cardiogenic shock and severe respiratory failure. J. Med. Invest. 73 : 561-565, August, 2026

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Cite This Study

Terazawa et al. (2026) conducted a case report in Fulminant giant cell myocarditis complicated by cardiogenic shock and severe hypoxemic respiratory failure due to Mendelson syndrome (n=1). Stepwise ECMO conversion strategy (V-A to V-AV to V-V ECMO) with IMPELLA support (ECPELLA) was evaluated on Weaning from extracorporeal support and recovery of cardiopulmonary function. Stepwise ECMO reconfiguration (V-A to V-AV to V-V) with IMPELLA resolved differential hypoxia and improved LVEF from 5% to 45%, enabling weaning by day 10.

synapsesocial.com/papers/6af5bf07e94012e8747ad98f https://doi.org/10.2152/jmi.73.561

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Stepwise extracorporeal membrane oxygenation conversion strategy with IMPELLA support in giant cell myocarditis complicated by severe hypoxemic respiratory failure due to Mendelson syndrome:A case report

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Stepwise extracorporeal membrane oxygenation conversion strategy with IMPELLA support in giant cell myocarditis complicated by severe hypoxemic respiratory failure due to Mendelson syndrome:A case report

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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