Discussion
We present a case of a previously
healthy young man who presented with cardiogenic shock of unknown
etiology and respiratory failure with multiple negative SARS-CoV-2
RT-PCRs. He required LVAD implantation, and postoperative period was
complicated by nosocomial SARS-CoV-2 pneumonia. To the best of our
knowledge this is the first case report of COVID-19 in the immediate
postoperative period of LVAD implantation. In this report we demonstrate
that COVID-19 was associated with RVF in the setting of respiratory
failure.
Right ventricular failure complicates 4-50% of LVAD
implants12, and our patient was just in this delicate
phase when he developed COVID-19. Although RVF can be a consequence of
LVAD implantation, the patient did not present clinical or
echocardiographic signs of RVF until he required noninvasive MV.
Therefore, COVID-19 probably had a main contribution to RVF in this
case.
The new coronavirus is associated with RVF by multiple mechanisms.
Severe pneumonia and ARDS may lead to RVF14. The
pathophysiology is multifactorial: hypoxia, vascular alterations, MV and
hypercapnia all together may lead to pulmonary hypertension and
RVF14. Myocardial injury has also been described in
COVID-19, worsening biventricular function13. Our
patient presented extreme troponin elevation after LVAD implantation,
which could be due to the surgical procedure or a superimposed
myocardial injury secondary to the new coronavirus.
A systematic review was performed searching PubMed and MEDLINE and using
the keywords “LVAD” and “COVID-19” for comparison with this case.
The selection criteria were case reports or case series of LVAD
recipients and positive SARS-CoV-2 RT-PCR. Pre-specified demographic and
prognostic data was collected. A total of 157 publications were found,
and 8 publications met the selection criteria.
Fourteen patients are described
(Table 3). The mean age was 62.7 years and 78.5% were male. The time
since LVAD implant varied from 0.03 months to 6.8 years, and none of
them happened in the immediate postoperative period. Five patients
(35.7%) required MV and 3 patients (21.4%) died. Two patients (14.2%)
had thromboembolic events. Six patients (42.8%) had mild symptoms, and
three were followed as outpatients.
As expected, LVAD patients with COVID-19 had higher mortality than
general population. Data from China shows a mortality rate of
2.3%2, while in this systematic review LVAD
recipients had a fatality rate of 21.4%, probably because they have
multiple comorbidities and live in a functionally immunocompromised
state3. In contrast, our patient eventually recovered
despite multiple complications, probably because of young age and lack
of other comorbidities.
Mechanical ventilation was required in 35.7% of patients, while in
general population only 14% present pneumonia and 5% require
MV2. Despite frequent need for MV in LVAD patients and
the concern about RVF in this population, in this systematic review only
one patient presented RVF requiring inotropes6. This
patient had mild symptoms of COVID-19 and did not present SARS-CoV-2
pneumonia or myocardial injury, so that RVD was not thought to be
related to COVID-19.
The new coronavirus is also associated with high thromboembolic rates,
and studies reported thromboembolism incidence of 25% in critical
patients15. LVAD recipients in parallel are in
intrinsic risk of pump thrombosis. This may raise a concern about
thromboembolic events (TE) in this population. However, chronic
anticoagulation may play a protective role since so far only 14.2% had
TE while infected5, 8.
This study has limitations. All publications are case reports or case
series. There is clinical heterogeneity between patients regarding age,
type of LVAD and time since LVAD implantation. Mild cases of COVID-19
might be underrepresented. Despite these limitations, this is the first
systematic review of LVAD and COVID-19. Also, the present case report
illustrates the vulnerability of LVAD recipients regarding RVF in the
perioperative setting.
In this systematic review, LVAD recipients with COVID-19 had a higher
mortality and morbidity than general population. More study is needed to
better understand COVID-19 in LVAD recipients.