Abstract
A 43-year-old man was admitted to our hospital for complete atrioventricular block. Temporary ventricular pacing worked optimally. Transthoracic echocardiography revealed diffuse hypokinesis of left ventricular wall. Calculated left ventricular ejection fraction was 0.28 and measured cardiac index was 2.0l·min-1·m-2. The patient was found to have ALT of 9350 IU·l-1, arterial ketone body ratio of 0.61 and hepaplastin test of 27%. The working diagnosis was acute fulminant myocarditis accompanied by severe hepatic dysfunction. Because the patient's hemodynamics did not improve in response to administration of catecholamines and cardiac index decreased to 1.7l·min-1·m-2, percutaneous cardiopulmonary support system (PCPS) and intraaortic balloon pumping (IABP) were induced to treat circulatory insufficiency 12h after admission. Following arrival at the ICU, the patient's trachea was intubated. Plasma exchange combined with continuous hemodiafiltration was induced to treat hepatic and renal dysfunction. On the fifth day, PCPS was successfully discontinued. On the seventh day, IABP catheter was surgically removed and the patient's trachea was successfully extubated. The patient was discharged from hospital three months later. Clinical features and findings of right ventricular endomyocardial biopsy demonstrated acute fulminant myocarditis. We believe that ischemic hepatic injury may play, an important role in the development of severe hepatic dysfunction. We recommend that mechanical circulatory support system should be immediately induced to improve hepatic circulation when patients with acute fulminant myocarditis result in severe hepatic dysfunction.
