Case Review, COVID-19, AMI Cardiogenic Shock, Protected PCI
Treatment of a COVID-19 Patient Using Impella 5.5® with SmartAssist®
David D’Alessandro, MD presents the case of a 44-year-old woman presenting to the ER 8 days after the onset of chills, myalgia, sore throat, and cough. Her husband tested positive for COVID-19 infection and her PCP advised her to self-quarantine. She presented to the ER at Massachusetts General Hospital with chest pain and shortness of breath.
While her chest x-ray showed clear lung fields without evidence of pneumonia, a chest CT with IV contrast showed scattered ground glass opacities consistent with an inflammatory or infectious etiology. She was admitted to the CCU. An echo revealed a dilated, dysfunctional left ventricle. She was placed on V-A ECMO, but the next morning there was evidence of LV worsening with moderate mitral regurgitation and it became apparent that the LV needed to be unloaded.
The cath lab was concerned with exposing cath lab staff to COVID-19, so she was taken to the OR for axillary placement of Impella 5.5®, a strategy Dr. D’Alessandro describes as common for getting patients off ECMO as soon as possible. Her myocarditis was progressing, so they took her off ECMO and put her on percutaneous biVAD support with an oxygenator.
Dr. D’Alessandro describes some Impella 5.5 positioning challenges and expresses gratitude for the Impella Connect® feature. “I will say, it was a real advantage to having the Abiomed team being able to follow along in real-time with this patient using the Impella Connect interface,” he notes, “and they were able to communicate with the team and give us really helpful pointers about what we could do to help us better balance flows.”
The team saw pretty good decompression of both the left and right ventricles when the patient was supported on both sides. Dr. D’Alessandro reports that she was given 4 doses of intravenous immunoglobulin (IVIG) for presumed myocarditis and the team saw progressive improvement in pulmonary function. The oxygenator was removed from the RVAD circuit on hospital day 4 and she was decannulated from support on hospital day 6. At the time of the interview, Dr. D’Alessandro noted that she looked good clinically but several of her inflammatory markers (eg, ESR, CRP, D-dimer) remained elevated.
“Cardiac manifestations in this illness are common and when they’re present, they significantly and negatively impact patient prognosis,” states Dr. D’Alessandro. “Actually, the highest risk factor of death is a cardiac component to the illness.” In his review of the case, he emphasizes, “I think it’s definitely true that, when timed well, that the appropriate application of cardiac, with or without pulmonary support, can be lifesaving. And it certainly was in this patient.”
In addition, when treating such patients, Dr. D’Alessandro notes, “Anticoagulation regimen may need to be modified. It’s very clear that these patients have a revved-up coagulation cascade. It’s not clear whether we should be using higher doses of heparin or, perhaps, direct thrombin inhibitors.” He concludes the case review with this observation. “I think…as we learn more and more and as we discuss these in forums like this, I think it’s going to be critically important for, not only our understanding now, but our understanding for when we have to combat future epidemics, which will undoubtedly arise.”