Severe COVID-19-associated myocarditis with cardiogenic shock - management with assist devices - a case report & review

Abstract

Background: Primary viral myocarditis associated with severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) infection is a rare diagnosis.

Case presentation: We report the case of an unvaccinated, healthy patient with cardiogenic shock in the context of a COVID-19-associated myocarditis and therapy with simultaneous veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and percutaneous left ventricular decompression therapy with an Impella. The aim of this review is to provide an overview of therapeutic options for patients with COVID-19-associated myocarditis.

Conclusions: The majority of patients required a combination of two assist devices to achieve sufficient cardiac output until recovery of left ventricular ejection fraction. Due to the rapid onset of this fulminant cardiogenic shock immediate invasive bridging therapy in a specialized center was lifesaving.

Keywords: Critical care; Extracorporeal membrane oxygenation; Heart failure; Impella; Myocarditis; SARS-COV-2.

Fig. 1

Clinical and laboratory findings Figure 1 depicts laboratory results, dosing, measurement results and ECMO settings. Abbreviations: MAP, mean arterial pressure; HR, heart rate; IVS, interventricular septum thickness; NTG, nitroglycerine; LPM, liter per minute; FiO2, inspirational oxygen concentration; TropT, troponin T; CKMB, Creatine kinase myocardial band; CK, Creatin kinase; pip/Taz, piperacillin tazobactam; Hb, Haemoglobin; RBC, red blood count; TC, thrombocyte count; FFP, fresh frozen plasma; PPSB, prothrombin complex concentrate; ASS, aspirin; aXa, anti-Xa activity; aPTT, activated partial thromboplastin time; IL-6, interleukin 6; CRP, C-reactive protein

Fig. 2

Transthoracic echocardiography. A Day 1. Severely impaired cardiac function, left ventricular ejection fraction ~ 20%, interventricular septum thickness (IVS) 14 mm, circular pericardial effusion (< 8 mm end-diastolic). B Day 2. IVS 21 mm, lateral wall thickness 25 mm, pericardial effusion (11 mm). C Day 15. Normalized cardiac function, left ventricular ejection fraction 65%, IVS 8 mm, no pericardial effusion.

Fig. 3

PRISMA flow diagram. Graphical representation of the systematic literature review according to the PRISMA reporting guideline. Abbreviations: SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. Most of the patients in the case studies were male (m 10, f 3) and the median age was 42.6 years (interquartile range 22.5–56 years). Only three patients had reported cardiovascular risk factors diabetes and hypertension in their medical history. One of them already had two previously implanted permeable stents and an ischemic heart disease without chronic heart failure before COVID-19 myocarditis. Pulmonary manifestation in the form of pneumonia was only reported in one patient and acute respiratory distress syndrome (ARDS) was only reported in four patients of 13 cases [–16, 21]. One of these four patients with ARDS requiring veno-arterio-venous ECMO (VAV-ECMO) due to ARDS [13].