Rescue Venoarterial Extracorporeal Membrane Oxygenation After Cardiac Arrest in COVID-19 Myopericarditis: A Case Report

Abstract

Coronavirus Disease-2019 (COVID-19) has been associated with potentially life threatening cardiovascular complications, including fulminant myocarditis and cardiac tamponade. Optimal management strategies are still unclear, including the role of immunomodulatory therapies and extracorporeal membrane oxygenation (ECMO) in the context of cardiogenic shock. We report a case of a middle-aged female with COVID-19 who developed respiratory distress and hemodynamic deterioration with elevated troponin levels on the seventh day of symptoms. Echocardiography demonstrated pericardial effusion with diastolic restriction of the right ventricle. Cardiac arrest developed during pericardiocentesis, resulting in emergency thoracotomy and pericardial drainage. Venoarterial ECMO was subsequently initiated due to refractory cardiogenic shock. Tocilizumab, immunoglobulin, methylprednisolone and convalescent plasma were added to supportive care, with progressive recovery of cardiac function and successful weaning from mechanical ventilation. This case highlights the potential role of ECMO, convalescent plasma and immunomodulatory therapies in the management of cardiogenic shock associated with COVID-19 myopericarditis.

Veno‐arterial extracorporeal membrane oxygenation for COVID‐19‐associated acute myocardial injury complicated by refractory cardiogenic shock

“…2 The role of VA-ECMO in the management of patients with COVID-19 acute myocardial injury is still unclear and the existing literature is limited to isolated case reports. [6][7][8] Although cardiac injury usually appears within the context of the overall respiratory infection rather than the first manifestation of disease, 6 our patient rapidly evolved towards a refractory cardiogenic shock successfully rescued with VA-ECMO. Interestingly, Sampaio et al 8 published a case of COVID-19 myopericarditis complicated by tamponade and cardiac arrest and eventually managed with VA-ECMO, thus highlighting the wide and potentially life-threatening phenotypic presentation of isolated COVID-19 acute myocardial injury.…”

“…Acute myocardial injury is reported in more than 20% of COVID‐19 patients and yields increased mortality 2 . The role of VA‐ECMO in the management of patients with COVID‐19 acute myocardial injury is still unclear and the existing literature is limited to isolated case reports 6–8 …”

“…Although cardiac injury usually appears within the context of the overall respiratory infection rather than the first manifestation of disease, 6 our patient rapidly evolved towards a refractory cardiogenic shock successfully rescued with VA‐ECMO. Interestingly, Sampaio et al 8 published a case of COVID‐19 myopericarditis complicated by tamponade and cardiac arrest and eventually managed with VA‐ECMO, thus highlighting the wide and potentially life‐threatening phenotypic presentation of isolated COVID‐19 acute myocardial injury. Accordingly, ARDS did not complicate the clinical course of our patient neither in the initial phase nor during VA‐ECMO support, as previously described 7,8 .…”

“…Interestingly, Sampaio et al 8 published a case of COVID‐19 myopericarditis complicated by tamponade and cardiac arrest and eventually managed with VA‐ECMO, thus highlighting the wide and potentially life‐threatening phenotypic presentation of isolated COVID‐19 acute myocardial injury. Accordingly, ARDS did not complicate the clinical course of our patient neither in the initial phase nor during VA‐ECMO support, as previously described 7,8 . Conversely, Tavazzi et al 6 published the first case of biopsy‐proven myocardial localization of SARS‐CoV‐2 viral particles presenting with cardiogenic shock rescued with VA‐ECMO and then switched to veno‐arterial‐venous ECMO as a consequence of severe persistent hypoxemia.…”

Fulminant Delta COVID-19 myocarditis: a case report of fatal primary cardiac dysfunction

“…A very small number of case reports describe patients with severe cardiac dysfunction requiring MCS; however, they all a demonstrated recovery of cardiac function within 7 days. 5–8 Two of those patients suffered cardiac arrest prior to the initiation of MCS; however, both had alternative reasons to arrest (cardiac tamponade 7 and during insertion of pulmonary artery catheter 6 ).…”