ECMO for Critically Ill COVID-19 with ARDS: A Case Series

Introduction Veno-venous extracorporeal membrane oxygenation (VV-ECMO) as bridge to recovery in critically ill COVID-19 continues to be commonly utilized strategy in cases with persistent respiratory failure refractory to traditional ventilation support Case Report We report 5 cases of severe acute respiratory syndrome coronavirus-2 infection (SARS-CoV-2) who were treated with ECMO (Table 1). All 5 cases presented with fever, cough and shortness of breath and a positive nasopharyngeal swab for SARS-CoV-2 on admission. Case 1, 2, 3 and 5 patients were hypoxemic with saturation less than 90% on admission and decompensated rapidly, whereas Case 4 decompensated after day 14. Mechanical ventilation failed to provide adequate oxygenation in all 5 cases;case 2,3 and 5 were started on recruitment measures with proning while it was not possible for case 1 owing to morbid obesity. Proning was not possible in the case 4 as patient became severely hypoxemic while patient was undergoing mechanical thrombectomy. The case 1-4 remained on ECMO for 19, 17, 17 and 2 days respectively. All except case 2 had improvement in APACHEII and SOFA score after ECMO initiation. All 5 patients had elevated inflammatory markers of serum ferritin, D-dimer, Lactate dehydrogenase (LDH), C-reactive protein (CRP) which trended down after a few days of ECMO initiation All 5 patients received high dose steroids during their stay in the ICU. Case 4 and 5 passed away after compassionate extubation. Case 1-3 had prolonged hospital course with complication of hospital acquired pneumonia requiring multiple courses of broad-spectrum antibiotics. Summary Our observational report of 5 patients reports the use of ECMO in critically ill SARS-CoV-2 with ARDS and difficult to maintain saturation despite mechanical ventilation and proning with recovery for 3 patients. However, given the lack of ECMO centers;this is not a readily available option. Further studies are warranted to investigate the role of ECMO in SARRS-CoV-2 and careful identification of appropriate candidates.

“Clots and Failures” A Case of COVID-19 Causing STEMI and Persistent Cardiogenic Shock Ultimately Requiring LVAD

Introduction We present a case of COVID-19 causing hypercoagulability and inflammatory stress leading to STEMI in a patient who went on to develop persistent cardiogenic shock requiring LVA) implantation. Case Report 57-year-old lady developed COVID-19 infection in May 2020. In June 2020, she presented with chest pain, was noted to have STEMI on EKG, complicated by cardiac arrest with ROSC in 14 minutes. She was in cardiogenic shock as well and was started on veno-arterial ECMO. She underwent left anterior descending artery stent placement. Further hospitalization was complicated by persistent cardiogenic shock and complete heart block and underwent pacemaker and cardiac-defibrillator implantation. She developed pulmonary edema, acute kidney injury requiring hemodialysis, shock liver, and persistent cardiogenic shock. She was weaned off VA-ECMO after 4 days but continued to have severely reduced cardiac function. RHC revealed severe volume overload, pulmonary venous hypertension, low cardiac output, and right heart dysfunction. Echo showed severe LV dysfunction with an EF of 15%. A femoral intra-aortic balloon pump(IABP) was placed on July 7, 2020. An attempt was made to wean her off of IABP on July 10th,however, it was unsuccessful and she was transitioned to axillary intra-aortic balloon pump. She remained IABP dependent thereafter and on July 15th, given persistent cardiogenic shock, decision was made to pursue advanced heart failure therapies. After multi-disciplinary discussion, the decision to pursue LVAD implantation was made. She underwent a successful LVAD implantation on July 20th . She failed an extubation trial and underwent tracheostomy on July 23rd . Post LVAD, she developed atrial fibrillation and was started on digoxin and amiodarone. Her symptoms improved and she was subsequently discharged to rehabilitation in late August on amiodarone, digoxin, metoprolol, prasugrel, warfarin, spironolactone and lisinopril. The detailed timeline is shown in figure 1. Summary Hypercoagulability and severe inflammatory stress leading to life-threatening illness is a significant complication of COVID-19 infection. A low threshold for suspecting and treating hypercoagulability and inflammatory induced myocardial ischemia and injury and cardiogenic shock is a reasonable strategy to decrease acute as well as chronic morbidity and mortality.

Telehealth for Left Ventricular Assist Device Patients: Current Perceptions and Practices in the United States

Purpose Telehealth services increased during the COVID-19 pandemic but barriers to expansion of telemedicine use for LVAD patients are not well described. This study evaluated perceptions of telehealth and patterns of use at LVAD centers across the USA. Methods An online, de-identified, 19 question survey was distributed across the USA to 53 LVAD centers participating in the FLIGHT and IDEAL HF working groups. A maximum of one physician and one VAD coordinator completed the survey at each center. Results The 62 respondents included 34 heart failure cardiologists, 11 cardiothoracic surgeons, 7 LVAD advanced practitioners and 10 LVAD RNs who were geographically well distributed across the USA. The majority (73%) of respondents worked at centers managing >75 LVAD outpatients and 66% provided care for LVAD patients living in rural areas. Thirty-seven percent of respondents had completed >10 telehealth visits for LVAD patients, and 90% had used telephone visits and 94% video visits. Most respondents (87%) completed telehealth visits for routine care with only 17% using telemedicine visits for acute issues and 10% for post-discharge visits. Fifty-three percent and 26% of providers did not feel comfortable making antihypertensive or diuretic medication changes, respectively, during telehealth visits. Use of remote patient monitoring (RPM) devices for tracking blood pressure or activity levels was low (Figure: top panel). Seventeen percent of providers were unsatisfied with patient care during telehealth visits. The most common barriers to increased adoption of telehealth visits for LVAD patients included patient access to technology and reimbursement considerations (Figure: bottom panel). Conclusion Telehealth visits are being used for LVAD patients but provider comfort level with medication changes during visits is low. Improved patient access to technology for RPM and video visits and expanded reimbursement of telehealth services may help to increase telemedicine usage for LVAD patients.

Changing Trends of Mean Pulmonary Artery Pressure Reading During Covid-19 Pandemic Stay at Home Orders

Introduction: Heart failure patients with difficult to manage volume status and recurrent heart failure exacerbation benefit from CardioMemsTM placement. This helps in remote monitoring of pulmonary artery (PA) pressure and diuretic dosing can be changed on the basis of these readings preventing hospitalizations. During the COVID-19 pandemic, a stay-at-home order was issued by the state government, which may have led to heart failure deterioration secondary to poor follow up and change in dietary habits. Hypothesis: We aim to evaluate changes in the mean PA pressure during stay-at-home order during COVID-19 pandemic as patients are not seen in clinic and there are presumed changes in dietary habits. Methods: We identified 26 patients with a history of CardioMemsTM implant using our heart failure clinic database. We extracted their daily available PA pressure reading before the COVID-19 pandemic and during pandemic. Results: The characteristics of the patients are described in Table 1. 26 cases with were identified with sufficient CardioMemsTM readings. Average age was 69.7 years with 38.5% females. There were 54% patients with systolic heart failure. Number of COVID-19 cases rose to almost 700 in 1 month. With regression analysis, we observed a trend towards increase in the mean PA pressure readings during the pandemic (R2 = 0.09, P-value<0.05). The patients also developed symptoms of heart failure exacerbation and were managed remotely with the changes in their medications (57% of cases). The trend of the change in the mean PA pressure readings during pandemic is presumably attributed to decreased activity and dietary changes as patients are staying at home and possibly consuming more canned food. However, none of these patients were hospitalized for heart failure exacerbation suggesting patients being scared of coming to the hospital because of the risk of transmission of COVID-19. Conclusions: There is an increase in the mean PA pressure during pandemic compared to that of before pandemic likely because of lack of proper food resources and restriction on exercise activity.