European Heart Journal Supplements: Diagnostic Strategies for Patients with Fulminant Myocarditis by Dr. Nicoletta D’Ettore

Key Takeaways:

• Endomyocardial Biopsy: Crucial for diagnosing cardiac inflammation especially when MRI is impractical due to cardiogenic shock or mechanical support.
• Role of Temporary Mechanical Circulatory Support (tMCS):  Impella™ heart pumps alone, or in combination with ECMO, as early unloading strategy in the Impella™ heart pumps with ECMO configuration, reduces afterload, myocardial wall stress, and oxygen demand and improves systemic and coronary antegrade perfusion.
• Heart Team Approach: Collaborative heart teams guide management decisions on support strategies, biopsy timing, transplant evaluation, and recovery planning.
• Reversibility of Fulminant Myocarditis: This acute, severe condition is potentially reversible with timely diagnosis and intervention, particularly in young, otherwise healthy individuals.

Nicoletta D’Ettore, MD, discusses key aspects of her paper, “Diagnosis and management of patients with fulminant myocarditis,” published in the 2025 European Heart Journal supplement titled “Mechanical Circulatory Support in Special Settings: the Heart Team Approach.” Dr. D’Ettore is a cardiologist at San Giacomo Hospital in Alessandria, Italy.

Dr. D’Ettore explains that endomyocardial biopsy, the gold-standard for confirming cardiac inflammation, should be considered to help guide treatment when diagnosing fulminant myocarditis, especially because cardiac magnetic resonance imaging is difficult to perform in patients in cardiogenic shock with ongoing mechanical circulatory support (MCS).

She highlights the important role of temporary MCS (tMCS) and unloading in these patients given that fulminant myocarditis is an acute and severe, but potentially reversible disease. “In extreme SCAI shock stages, with biventricular dysfunction, venoarterial ECMO is the most frequently used. Impella heart pumps alone, or in combination with ECMO, as early unloading strategy in the Impella™ heart pump with ECMO configuration, reduces afterload, myocardial wall stress, and oxygen demand and improves systemic and coronary antegrade perfusion.” She discusses the role of prolonged Impella support and unloading in mitigating cardiac inflammatory pathways.

“The heart team should be involved at each step of the clinical management of this complex and rapidly evolving condition,” Dr. D’Ettore emphasizes. “Patients with hemodynamically unstable heart failure with suspicion of myocarditis should be referred to tertiary center intensive care units experienced with mechanical support, with endomyocardial biopsy, and when possible, with heart transplant. And in this context, subsequently the heart teams should discuss the choice of mechanical support, the need of escalation or de-escalation therapy, the right timing for biospy, the possible indication to have transplant, and then the medical therapy and the long-term follow-up.”

In her concluding remarks, Dr. D’Ettore repeats the key message that fulminant myocarditis is potentially reversible with native heart recovery. So in this regard, timely and safe diagnosis and implantation of mechanical support is warranted in an otherwise healthy and young population.