Venoarterial extracorporeal membrane oxygenation (VA ECMO) has been considered as the first-line treatment for acute fulminant myocarditis (AFM) when traditional treatment is ineffective. Peripheral vascular VA ECMO can partially reduce right ventricular preload, but it can increase left ventricular (LV) afterload.1 The increased afterload may cause difficulty in LV blood ejection in patients with severely impaired LV function. In addition, it may result in secondary LV dilatation, pulmonary edema, intraventricular thrombosis, and even increased LV diastolic pressure, leading to myocardial ischemia and irreversible cardiac function, affecting the prognosis of the disease.2 Timely LV decompression can help to improve the prognosis.3 Here, we report a successful case of applying a surgical minimal invasive left atrial decompression method, and we discuss the appropriate timing and method of LV decompression during ECMO supporting in pediatric AFM. A 2-year-old girl with AFM was implanted with VA ECMO because of cardiac shock refractory to conventional therapy. The pulse pressure difference was less than 10 mm Hg, the LV ejection fraction (LVEF) was 20% and the LV dilated diameter (LVDD) was 36 mm while ECMO initiated. In addition, fluid intake was limited to 60% of normal physiological requirements. Epinephrine was maintained at 0.3 µg/kg/min. ECMO blood flow was titrated to mean arterial blood pressure (MABP) >50 mm Hg and venous oxygen saturation >65% to reduce LV afterload as low as possible. Urine output and serum lactate were monitored. On the 24th hour of ECMO running, the MABP increased to 80 mm Hg and pulse pressure difference declined to less than 5 mm Hg. Echocardiography showed that the LVEF decreased to 10%, LVDD increased …

中文翻译：

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小儿急性暴发性心肌炎静脉动脉体外膜氧合期间手术微创左心房减压

当传统治疗无效时，静脉动脉体外膜肺氧合（VA ECMO）被认为是急性暴发性心肌炎（AFM）的一线治疗方法。外周血管VA ECMO可部分降低右心室前负荷，但可增加左心室（LV）后负荷1。后负荷增加可能导致左心室功能严重受损患者左心室射血困难。此外，还可能继发左室扩张、肺水肿、心室内血栓形成，甚至左室舒张压升高，导致心肌缺血和心功能不可逆，影响疾病的预后。2 及时的左室减压有助于改善预后.3 在这里，我们报告一个应用外科微创左心房减压方法的成功案例，我们讨论了 ECMO 支持儿科 AFM 期间 LV 减压的适当时机和方法。一名患有 AFM 的 2 岁女孩因心脏休克对常规治疗无效而植入 VA ECMO。启动 ECMO 时，脉压差小于 10 mm Hg，左室射血分数 (LVEF) 为 20%，左室扩张直径 (LVDD) 为 36 mm。此外，液体摄入量被限制在正常生理需求的 60%。肾上腺素维持在 0.3 µg/kg/min。ECMO 血流量滴定至平均动脉血压 (MABP) > 50 mm Hg 和静脉血氧饱和度 > 65%，以尽可能降低 LV 后负荷。监测尿量和血清乳酸。ECMO运行第24小时，MABP升至80 mm Hg，脉压差降至5 mm Hg以下。