Case Review, COVID-19, ECMO, Surgical Applications
Impella® Support for COVID-19 Myocarditis
Amit Pawale, MD presents the case of a 56-year-old male with COVID-19 myocarditis. Dr. Pawale, a cardiac surgeon at Northwestern Medicine, describes how he and his team used ECMO to oxygenate the patient and Impella® heart pumps to unload the patient’s left ventricle.
The patient had no major comorbidities and presented to the emergency department with shortness of breath. He desaturated to 60% and was intubated. He was cardioverted for atrial fibrillation with rapid ventricular response (RVR), given volume, and treated with 3 high-dose pressors (epinephrine, norepinephrine, and vasopressin). His creatinine was 2.0 mg/dL, lactate 8 mmol/L, BNP 800 pg/mL, troponin I 1.3 ng/mL, and D-dimer 1,900 ng/mL.
TTE in the emergency department revealed a left ventricular ejection fraction (LVEF) of 25% with left ventricular wall thickness greater than 2 cm and a rim of pericardial effusion. The team initiated right fem-fem V-A ECMO support. Lactate improved and pressor requirements came down. The patient was transferred to the ICU and repeat TTE showed LVEF of 5-10%. The cath lab team placed a left femoral Impella 2.5® to unload the ventricle to promote ventricular recovery and avoid pulmonary edema associated with COVID-19 pneumonia.
Over the next 2 days, the patient was treated with methylprednisolone and tocilizumab while on ECMO support. Patient became anuric, with high vasoconstrictor requirements, and required multiple transfusions. CT scan revealed retroperitoneal hematoma. The team decannulated the V-A ECMO in the OR, removed Impella 2.5, and inserted an axillary Impella 5.0® and began V-V EMCO with a ProtekDuo (LivaNova) with oxygenator. LVEF improved to 50% but the patient had severe vasoplegia, volume overload, and hypoxemia.
The team aggressively removed about 20 liters of volume over the next 3 days. On day 9, they began weaning Impella 5.0 and on day 10 removed it at bedside. V-V ECMO was then removed and on day 14 the patient had a tracheostomy. Patient is still slowly recovering in ICU. TTE at 2 weeks on low dose inotropes showed that the left ventricle had recovered with LVEF of 65%.