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.