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Risk stratification of myocarditis is challenging due to variable clinical presentations. Cardiovascular magnetic resonance (CMR) is the primary non-invasive imaging modality to investigate myocarditis while electrocardiograms (ECG) are routinely included in the clinical work-up. The association of ECG parameters with CMR tissue characterisation and their prognostic value were investigated in patients with clinically suspected myocarditis. Consecutive patients with suspected myocarditis who underwent CMR and ECG were analysed. Major adverse cardiovascular event (MACE) included all-cause death, hospitalisation for heart failure, heart transplantation, documented sustained ventricular arrhythmia, or recurrent myocarditis. A total of 587 patients were followed for a median of 3.9 years. A wide QRS-T angle, low voltage and fragmented QRS were significantly associated with late gadolinium enhancement. Further, a wide QRS-T angle, low voltage and prolonged QTc duration were associated with MACE in the univariable analysis. In a multivariable model, late gadolinium enhancement (HR: 1.90, 95%CI: 1.17-3.10; p = 0.010) and the ECG parameters of a low QRS voltage (HR: 1.86, 95%CI: 1.01-3.42; p = 0.046) and QRS-T-angle (HR: 1.01, 95%CI: 1.00-1.01; p = 0.029) remained independently associated with outcome. The cumulative incidence of MACE was incrementally higher when findings of both CMR and ECG were abnormal (p<0.001). In patients with clinically suspected myocarditis, abnormal ECG parameters are associated with abnormal tissue characteristics detected by CMR. Further, ECG and CMR findings have independent prognostic implications for morbidity and mortality. Integrating both exams into clinical decision-making may play a role in risk stratification in this heterogeneous patient population.

The role of veno-venous extracorporeal membrane oxygenation therapy (V-V ECMO) in severe COVID-19 acute respiratory distress syndrome (ARDS) is still under debate and conclusive data from large cohorts are scarce. Furthermore, criteria for the selection of patients that benefit most from this highly invasive and resource-demanding therapy are yet to be defined. In this study, we assess survival in an international multicenter cohort of COVID-19 patients treated with V-V ECMO and evaluate the performance of several clinical scores to predict 30-day survival. Methods: This is an investigator-initiated retrospective non-interventional international multicenter registry study (NCT04405973, first registered 28 May 2020). In 127 patients treated with V-V ECMO at 15 centers in Germany, Switzerland, Italy, Belgium, and the United States, we calculated the Sequential Organ Failure Assessment (SOFA) Score, Simplified Acute Physiology Score II (SAPS II), Acute Physiology And Chronic Health Evaluation II (APACHE II) Score, Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) Score, Predicting Death for Severe ARDS on V-V ECMO (PRESERVE) Score, and 30-day survival. Results: In our study cohort which enrolled 127 patients, overall 30-day survival was 54%. Median SOFA, SAPS II, APACHE II, RESP, and PRESERVE were 9, 36, 17, 1, and 4, respectively. The prognostic accuracy for all these scores (area under the receiver operating characteristic—AUROC) ranged between 0.548 and 0.605. Conclusions: The use of scores for the prediction of mortality cannot be recommended for treatment decisions in severe COVID-19 ARDS undergoing V-V ECMO; nevertheless, scoring results below or above a specific cut-off value may be considered as an additional tool in the evaluation of prognosis. Survival rates in this cohort of COVID-19 patients treated with V-V ECMO were slightly lower than those reported in non-COVID-19 ARDS patients treated with V-V ECMO.

At the participating centers, all patients with reverse transcriptase polymerase chain reaction (rtPCR) positive testing for SARS-CoV-2, who received V-V ECMO from March 12 to June 5, 2020 (i.e., during the first wave of the pandemic), were included. [...]even though 90-day-survival of patients aged ≥ 71 years was significantly lower than for patients < 71 years, not all treatments in this elderly population ended fatal. [...]age limits should be viewed with caution and decisions for or against the use of ECMO for patients above 70 years of age should be performed on an individual case-by-case level. [...]our data may support the use of V-V ECMO in severe COVID-19 ARDS, also after prolonged periods of mechanical ventilation in selected patients. Collaborating authors (COVEC-study group): Jeff DellaVolpe, Methodist Hospital, San Antonio, Texas, USA; Dominik Scharpf, SLK-Hospital Heilbronn, Germany; Matthias Ulmer, RKH Hospital Ludwigsburg, Germany; Maximilian Halbe, Heart Center, University Hospital Zurich, Switzerland; Alexander Vogt, Department of Medicine III, University Clinic Halle (Saale), Germany; Raj Ramanan, University of Pittsburgh Medical Center (UPMC), Pennsylvania, USA; David Boldt, UCLA Healthcare System, Los Angeles, USA; Stephanie-Susanne Stecher, Medical Department II, LMU Hospital Munich, Germany; Andrea Montisci, Istituto Clinico Sant’Ambrogio, University of Milan, Italy; Tobias Spangenberg, Department of Cardiology, Angiology and Intensive Care, Marien Hospital Hamburg, Germany; Olivier Marggraf, Asklepios Clinic North, Hamburg, Germany; Chandra Kunavarapu, Methodist Hospital, San Antonio, Texas, USA; Lorenzo Peluso, Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium; Sebastian Muenz, SLK-Hospital Heilbronn, Germany; Monica Buerle, RKH Hospital Ludwigsburg, Germany; Naveen G. Nagaraj, Heart Center, University Hospital Zurich, Switzerland; Sebastian Nuding, Department of Medicine III, University Clinic Halle (Saale), Germany; Catalin Toma, University of Pittsburgh Medical Center (UPMC), Pennsylvania, USA; Vadim Gudzenko, UCLA Healthcare System, Los Angeles, USA; Hans Joachim Stemmler, Medical Department III, LMU Hospital Munich, Germany; Federico Pappalardo, Department of Anesthesia and Intensive Care, IRCCS ISMETT, UPMC Italy, Palermo, Italy; Georg Trummer, Department of Cardiovascular Surgery, Heart Center, University of Freiburg, Germany; Christoph Benk, Department of Cardiovascular Surgery, Heart Center, University of Freiburg, Germany; Guido Michels, Department of Acute and Emergency Care, St. Antonius Hospital Eschweiler, Eschweiler, Germany; Christoph Bode, Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany, Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Germany; Daniel Duerschmied, Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany, Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Germany; Constantin von zur Muehlen, Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany, Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Germany; Klaus Kaier, Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Germany, Institute of Medical Biometry and Statistics, Faculty of Medicine, University of Freiburg, Germany, Daniel Brodie, Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, USA, Center for Acute Respiratory Failure, Columbia University Medical Center, New York, USA; Tobias Wengenmayer, Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Germany, Department of Cardiology and Angiology I, Heart Center, University of Freiburg, Germany.