ABSTRACT
Introduction: Myocarditis is an inflammatory disease of cardiac muscle caused by a variety of infectious and non-infectious conditions. Viral infection is the most frequent cause of myocarditis;however, herpes simplex virus 1 (HSV-1) infection causing myocarditis has been rarely described. We present a case of a young woman with HSV-1 viremia and fulminant myocarditis presenting with cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO), complicated by hyperhemolysis. Case Report: A 35 year-old immunocompetent woman with moderate alcohol consumption presented to hospital with a 4-day history of fever and flu-like symptoms. She was fully vaccinated for COVID-19 two months prior to symptom onset. Her COVID-19 testing was negative and she was discharged home. She returned to hospital 4 days later in cardiogenic shock. Transthoracic echocardiogram demonstrated LVEF of 30% with a small pericardial effusion. Coronary angiogram revealed normal coronaries. She was placed on peripheral VA-ECMO for worsening cardiogenic shock. Due to inadequate LV unloading, she underwent atrial septostomy. Five days after VA-ECMO cannulation, HSV-1 was detected in the blood and she was started on intravenous acyclovir. Her ECMO course was complicated by acute kidney injury requiring dialysis, and hyperhemolysis with a peak LDH of 12,000 U/L. The mechanism of hemolysis was attributed to an intravascular process (plasma free hemoglobin 7487 mg/L, normal < 150 mg/L) likely from a combination cold agglutinins and the mechanical circuit. Interestingly the membrane pressure gradient was within normal. The patient received treatment with plasmapheresis (Table 1), and was eventually decannulated after 12 days following hemodynamic improvement. This case report highlights a rare viral cause of fulminant myocarditis and emphasizes the need for collaboration among various specialists in the management of complex cases.
ABSTRACT
Purpose The current COVID-19 pandemic has had an unprecedented impact on healthcare systems across the world. It has stretched to the limit acute care systems, indirectly it has shaped new and innovative ways to deliver care for those with chronic conditions. Herein we describe initial outcomes of the rapid virtualization of the Heart Function Clinic at a major quaternary Hospital in Toronto, Ontario. Methods Consecutive patients attending the heart function clinic at the Toronto General Hospital between March 9, 2020 and June 30, 2020 were included. Visits were classified as “in-person” if patients were physically present for the clinical interaction and “virtual” if the clinical interaction occurred while the patient was away using currently available modes of communication: telephone or web-enabled (Ontario Telemedicine Network -OTN, or other available web-based applications). The purpose of the individual visit was categorized as: “surveillance”, “titration”, “new assessment” or “Clinical trial”. Results A total of 292 patients had a total of 521 clinical encounters during the lockdown period. Of these, 168 (32.2%) were “in-person”, while 353 (67.8%) were “virtual”. 101 (19.3%) were primarily for the purposes of titration. These virtual assessments led to 14(2.7%) in-person assessments. 258 (49.5%) of patients had an LVEF < 40%, among these patients 220 (85.3%) were on an ACEi, ARB or ARNi, 242 (93.8%) on a Betablocker, 191 (74%) on an MRA, 46 (17.8%) on SGLT2inhibitor. Conclusion Rapid virtualization of a large academic multi-disciplinary clinic is possible. This allows for ongoing delivery of safe care to patients with chronic conditions and can be used as a model for other clinics facing the pandemic. Lessons learned will be used to transition to a hybrid model of in-person and virtual even after the pandemic has come to an end.