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6.3 Interventional techniques including

circulatory support 6.3.1. Myocarditis 6.3.1.1. Short-term mechanical circulatory support Myocarditis patients who present with rapid deterioration in haemodynamic status and rapidly progressive myocardial dysfunction are amongst those who respond best to temporary MCS.293 Among temporary MCS, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) represents the most frequently applied or recommended approach, ranging from 75% to 85% of AM cases.75,294–296 Despite the high risk and markedly compromised state of patients undergoing VA-ECMO support for FM, the prognosis is rather favourable, with a high rate of myocardial recovery and patient survival. Several national and international multicentre studies showed in-hospital survival ranging from 61% to 72%,297–300 but no freedom from HT in patients with giant-cell FM.294 Temporary MCS should be performed early and in a timely manner in patients with FM with refractory cardiogenic shock because of the high likelihood of recovery.

6.3.1.2 Intra-aortic balloon pump

As mentioned, EMB should be performed as soon as possible, even in the presence of temporary MCS,212,295 and specific immunosuppressive therapy should be considered at least as an initial option, while determining the myocardial response.295 An intra-aortic balloon pump (IABP) should be considered in cardiogenic shock as first-line MCS with prompt escalation to more powerful MCS if haemodynamic and end-organ perfusion improvement is not observed within a short time (1 h maximum).295

6.3.2 Pericarditis

Pericardium-related interventional procedures are increasingly applied and require specific expertise.1,301 The use of percutaneous interventional techniques for pericarditis is not limited to perform percutaneous drainage, but also to obtain fluid samples for cytology and other pathological examinations (see Supplementary data online, Table S7). Moreover, interventional techniques are used to provide alternative treatment, such as balloon pericardiotomy or, less commonly, intrapericardial drug administration (e.g. corticosteroids or chemotherapy).

6.3.2.1 Pericardiocentesis and pericardial drainage

Percutaneous pericardiocentesis guided by echocardiography or fluoroscopy is indicated for CTP and symptomatic moderate to large PEffs

Recommendation Table 10 — Recommendations for medical therapy in pericarditis (see Evidence Table 10)

Recommendations Classa Levelb

Colchicine is recommended as first-line therapy in patients with pericarditis as an adjunct to aspirin/NSAID or corticosteroid therapy to reduce subsequent recurrences.24,25,108,275–278 I A Anti-IL-1 agents (anakinra or rilonacept) are recommended for patients with recurrent pericarditis after failure of first-line therapies and corticosteroids and elevation of C-reactive protein levels to reduce recurrences and allow corticosteroid withdrawal.108,275,282–284 I A High-dose aspirin or NSAIDs with proton pump inhibitors are recommended as first-line therapy in patients with pericarditis to control symptoms and reduce recurrences.291,292 I B A β-blocker should be considered in symptomatic patients, despite full anti-inflammatory therapy, and heart rate at rest >75 b.p.m. in order to improve symptom control.274 IIa C Anti-IL-1 agents (anakinra or rilonacept) should be considered in cases of incessant/recurrent pericarditis with evidence of pericardial inflammation on CMR after failure, contraindications, and intolerance to first-line therapies and corticosteroids regardless of C-reactive protein levels to reduce recurrences and allow corticosteroid withdrawal. IIa C Low- to medium-dosec corticosteroids should be considered for patients with pericarditis only in cases of contraindication/failure of aspirin/NSAIDs and colchicine, or when there is a specific indication to control symptoms and reduce recurrencesd. IIa C Hydroxychloroquine may be considered in patients with recurrent pericarditis refractory to standard therapy (including corticosteroids and anti-IL-1 agents) to prolong recurrence-free survival.290 IIb B Corticosteroids are not recommended as the first option for patients with pericarditis therapy without a specific indicationd. III C © ESC 2025

b.p.m., beats per minute; CMR, cardiovascular magnetic resonance; IL, interleukin; NSAID, non-steroidal anti-inflammatory drug. aClass of recommendation. bLevel of evidence. cSee Table 13. dFor example, systemic inflammatory disease on maintenance therapy with corticosteroids, post-pericardiotomy syndromes, post-vaccine pericarditis, severe renal failure, concomitant therapies interacting with NSAIDs such as oral anticoagulant. Recommendation Table 11 — Recommendations for interventional techniques including circulatory support in myocarditis (see Evidence Table 11)

Recommendations Classa Levelb

A timely and dedicated Shock Team discussion is recommended in patients with myocarditis in the presence of haemodynamic compromise, to decide on the need for escalation to MCS and to determine a long-term management plan. I C Temporary MCSc should be considered in patients with myocarditis and cardiogenic shock or acute decompensation in chronic myocarditis to stabilize the patients. IIa C © ESC 2025

IABP, intra-aortic balloon pump; MCS, mechanical circulatory support; PLVAD, percutaneous left ventricular assist device; VA-ECMO, veno-arterial extracorporeal membrane oxygenation. aClass of recommendation. bLevel of evidence. cIABP, PLVAD, VA-ECMO.

ESC Guidelines                                                                                                                                                                                          3993

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