Discussion
We report the successful treatment of a patient with probable COVID-19 induced cardiopulmonary failure, due to fulminant myocarditis, using a BIVAD with an extracorporeal membrane oxygenator. To our knowledge, there is only other one such case reported in the literature, and this patient died of a secondary bacterial infection on postoperative day 33 and prior to explantation [3]. Although VA-ECMO could also be considered and has been reported in the literature [8], this mode of support is not an effective long-term strategy and may lead to stasis of blood flow in the pulmonary circulation.
The clinical presentation was highly suspicious for COVID-19 despite negative SARS-CoV-2 antigen tests at the height of the UK component of the COVID-19 worldwide pandemic. Due to the initial unavailability of testing, he was only confirmed to be SARS-CoV-2 antibody positive four weeks post-BIVAD implantation. We conclude that he likely contracted COVID-19 before presentation to hospital, then subsequently succumbed to an overwhelming systemic inflammatory response, which resulted in cardiopulmonary failure.
Coagulopathy is a recognised complication of mechanical circulatory support and COVID-19 [9]. Initially, the patient was coagulopathic, so systemic heparinisation was delayed until postoperative day 3. An intracerebral bleed was detected on postoperative day 11 which later resolved. A significant bleed within the trachea complicated the percutaneous tracheostomy, which required packing, re-intubation and a return to theatre for exploration and resolution. Heparin infusions were discontinued for prolonged periods due to the intracerebral bleed, tracheostomy bleed and thrombocytopenia. Heparin-induced thrombocytopenia screen tests were negative and the thrombocytopenia resolved with discontinuation of the BIVAD and with continued platelet transfusions.
Our report documents one of the first reported successful cases of a patient with COVID-19 induced cardiopulmonary failure with BIVAD mechanical circulatory support. The outcome here suggests that COVID-19 patients with acute cardiogenic shock may be successfully managed with a BIVAD, but there are several challenges that may be encountered as well as significant resources required. Patient selection can be challenging and Chow et al. recommend that identification of potential clinical scenarios leading to cardiogenic shock and circumstances unique to COVID-19 may facilitate decision-making, ideally by a multidisciplinary team that includes representation of cardiac surgery, cardiology, intensive care, anaesthesia, as well as advanced heart failure and transplant physicians [10].
In this patient, we applied a proven emergency therapy to treat a patient with near fatal biventricular failure. The aetiology of the condition was not known at the initiation of BiVAD due to challenges in the availability of the SARS-CoV-2 antibody test. It is likely that cases of COVID-19-associated cardiogenic shock present several weeks after the initial infection, test negative for the SARS-CoV-2 antigen on presentation, and that such cases will continue to be seen in the future. We recommend that all healthcare professionals keep this diagnosis in mind when presented with a young, acutely unwell patient with cardiogenic shock of unknown aetiology, and refer such patients to their local transplant/mechanical circulatory support service.