ABSTRACT
INTRODUCTION: We present a case of a woman who tested positive for SARS-CoV2 admitted to ICU with cardiogenic shock related to severe myocarditis. A cathetermounted ventricular assist device (Impella® CP) was successfully implanted in the left heart. METHODS: A 40-year-old female (68 kg - 150 cm) with history of hypertension, presented at the ED complaining of shortness of breath and chest tightness. A SARS-CoV2 PCR test returned positive. The laboratory workup was drawn, CXR showed bibasilar opacities, and the EKG 0,6 mm ST elevations in I, II, V4-V6 leads and low voltages. CTA chest was unremarkable for PE. She received Dexamethasone as a treatment for COVID-19 and, convalescent plasma, Remdesivir and Tocilizumab were deferred due to transaminitis. Aspirin and Colchicine were concurrently started. Due to respiratory failure and hypotension she was emergently intubated, started on IV Norepinephrine, Dobutamine and Heparin infusions and admitted to ICU. Initial TTE showed severely reduced LV systolic function with wall motion abnormalities and moderate pericardial effusion without evidence of tamponade. Given elevated Troponin I and TTE results with sudden depressed LVEF 19,4% (previously 65%) concerning possible myocarditis, interventional cardiology was consulted for an Impella® CP placement under fluoroscopic guidance via transfemoral access in the right CFA. It achieved a blood flow of 3.1 L/ min supported CO with an immediate improvement in hemodynamic parameters. On day 3, a pericardial window was performed draining 300 ml. On day 8, Impella® CP was removed and she is successfully recovering in the ICU. RESULTS: Fulminant myocarditis represents a lifethreatening complication related to SARS-CoV2 infection. New-onset chest pain and Troponin elevation without past cardiovascular disease and severely reduced LVEF may raise the suspicion of myocarditis, rather than M infarction. Cardiogenic shock without improvement with conventional treatment represents the recent U.S. FDA approved indication for V-A ECMO or Impella® CP use in COVID-19 patients. Direct LV unloading provided by Impella® is considered an advantage over V-A ECMO. Its percutaneous placement results to be very useful in pandemic conditions. The Impella® CP used in our patient provided adequate support for LV function recovery.