Intensive Care Medicine | Published: 12 January 2026
Background
Temporary mechanical circulatory support (t-MCS) is
increasingly used in fulminant myocarditis (FM), yet long-term outcomes and
risk factors remain poorly defined.
Methods
From the FULLMOON international cohort (419 adults with
suspected FM across 36 centers in 15 countries), 295 patients treated with
venoarterial extracorporeal membrane oxygenation (V-A ECMO) and/or Impella were
analyzed. The primary endpoint was mortality at 1 year, heart
transplantation (HTx), or left-ventricular assist device (LVAD). Multivariate
Cox regression identified predictors of adverse outcomes. A propensity
score-weighted analysis assessed outcomes based on timing of endomyocardial
biopsy (EMB): early (≤ 2 days), delayed (> 2 days), or none.
Results
The median age was 39 years (IQR 28–60), and 55% were
female. Myocarditis was confirmed in 204 (69%) of the patients via histology or
cardiac MRI. Histological data were available for 151 (51%) of the cohort.
One-year mortality was 36%, while 44% died or had an HTx or LVAD. Predictors of
worse outcomes were giant cell myocarditis, older age, cardiac arrest at ECMO
initiation, and delayed EMB. Delayed EMB was consistently associated with
higher mortality, HTx, or LVAD compared to early (HR = 1.55;
95% CI 1.23–1.96; p < 0.01) or no EMB (HR = 1.59;
95% CI 1.26–2.01; p < 0.01). However, event-free survival did not differ
significantly between early EMB and no EMB (HR = 1.03; 95% CI 0.80–1.32; p = 0.85).
Conclusions
Despite a relatively young cohort, FM requiring t-MCS is
associated with a high 1-year mortality rate. Timely recognition and early
referral to specialized ECMO centers before cardiac arrest are critical.
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