Severe COVID-19 Myocarditis in a Young Unvaccinated Patient.

Coronavirus disease 2019 (COVID-19) myocarditis is a rare but serious complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and has been associated with high-case fatality. For a very long time, since the beginning of the pandemic, there were no definitive guidelines to diagnose and manage this condition, probably secondary to the gaps in understanding the exact pathophysiology of the disease. We present the case of a young, unvaccinated female, with no comorbidities, who had an aggressively progressive COVID-19 myocarditis that was fatal. The patient presented with exertional dyspnea of two days duration and was found to be tachycardic with a heart rate ranging between 130-150 beats per minute. A nasopharyngeal swab for SARS CoV-2 was positive and a bedside echocardiogram showed a low ejection fraction of 20%. Within hours of presenting, she experienced a rapid decompensation requiring intubation. Due to fulminant myocarditis with cardiogenic shock, the patient was planned for cardiac catheterization, Impella placement, and extracorporeal membrane oxygenation (ECMO) support. The cardiac catheterization revealed non-obstructive coronary arteries and the hemodynamics suggested biventricular failure. However, around the time of the cardiac catheterization procedure, she had two events of cardiac arrest with pulseless electrical activity and unfortunately could not be revived after the second arrest despite all resuscitative efforts.

Cardiogenic shock due to probable SARS-CoV-2 myocarditis-a case report.

Background: Since the start of the COVID-19 pandemic, many case reports have been presented describing different cardiac symptoms due to the SARS-CoV-2 infection. However, severe cardiac failure due to COVID-19 seems to be rare. Case summary: A 30-year-old woman presented with COVID-19 and cardiogenic shock due to a lymphocytic myocarditis. Since she deteriorated under treatment with inotropes, she was referred to our centre, and veno-arterial extracorporeal life support was started. Subsequently, the aortic valve only opened sporadically, and spontaneous contrast appeared in the left ventricle (LV), pointing towards difficulties with unloading LV. Therefore, an Impella for venting the LV was implanted. After 6 days of mechanical circulatory support, her heart function recovered. All support could be weaned, and 2 months later, she had made a full recovery. Discussion: We presented a patient with severe cardiogenic shock due to an acute virus-negative lymphocytic myocarditis associated with a SARS-CoV-2 infection. Since the precise aetiology of SARS-CoV-2-related myocarditis remains to be elucidated and no virus could be detected in the heart, a causal relationship remains speculative.

COVID-19 fulminant myocarditis recovered with veno-arterial extracorporeal membrane oxygenation and Impella CP.

A 38-year-old man without a history of coronavirus disease 2019 (COVID-19) vaccination presented with dyspnea and fever. Polymerase chain reaction nasopharyngeal swab for severe acute respiratory syndrome coronavirus 2 was positive. Electrocardiogram showed diffuse ST-segment elevation, and chest radiography showed mild pulmonary congestion. The left ventricular (LV) function was markedly impaired. Vital signs were unstable, and serum lactate level was elevated. The patient was diagnosed with cardiogenic shock due to COVID-19 fulminant myocarditis and received veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and Impella CP (Abiomed, Inc., Danvers, MA, USA). Remdesivir and intravenous immunoglobulin were also administered. Corticosteroids were not administered because of the absence of pneumonia. On admission, endomyocardial biopsy showed a small direct inflammatory infiltrate of the myocardium. During mechanical support, the cardiac function improved, the patient was weaned off VA-ECMO on day 6, and Impella CP on day 7. Cardiac magnetic resonance imaging implied recent myocardial damage. The patient was discharged on day 30, and the LV function fully recovered. Since the treatment and prognosis of COVID-19 fulminant myocarditis remain unclear, we report the course of COVID-19 fulminant myocarditis with favorable outcomes. Mechanical circulatory support might be an important factor in determining the prognosis of COVID-19 fulminant myocarditis. Learning objective: Coronavirus disease 2019 fulminant myocarditis sometimes requires mechanical circulatory support. The prognosis and treatment have not yet been adequately established. The prognosis is favorable if adequate hemodynamic support is provided.

Severe COVID-19-associated myocarditis with cardiogenic shock - management with assist devices - a case report & review.

BACKGROUND: Primary viral myocarditis associated with severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) infection is a rare diagnosis. CASE PRESENTATION: We report the case of an unvaccinated, healthy patient with cardiogenic shock in the context of a COVID-19-associated myocarditis and therapy with simultaneous veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and percutaneous left ventricular decompression therapy with an Impella. The aim of this review is to provide an overview of therapeutic options for patients with COVID-19-associated myocarditis. CONCLUSIONS: The majority of patients required a combination of two assist devices to achieve sufficient cardiac output until recovery of left ventricular ejection fraction. Due to the rapid onset of this fulminant cardiogenic shock immediate invasive bridging therapy in a specialized center was lifesaving.

Full myocardial recovery following COVID-19 fulminant myocarditis after biventricular mechanical support with BiPella: a case report.

Background: Fulminant myocarditis is a rare yet dreadful condition, which requires evaluation for mechanical support. The concomitant use of an Impella pump in the left and of one in the right ventricle-the so-called 'BiPella approach'-might allow recovery of the failing heart in selected cases. We report a peculiar case, in which mechanical circulatory support was used as the sole strategy to promote myocardial recovery, without the administration of any immunosuppressants in coronavirus disease (COVID)-19 fulminant myocarditis. Case summary: A previously healthy 49-year-black man presented to the emergency department with dyspnoea and severe metabolic acidosis. His nasopharyngeal swab resulted positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Echocardiography documented severe biventricular dysfunction which required support with two Impella pumps-the so-called 'BiPella approach'. Myocarditis was suspected on clinical basis. Endomyocardial biopsy showed SARS-CoV-2 localization within the endothelial cells. No antiviral or immunosuppressive therapy was administered. After 10 days of support, the patient was weaned from both right- and left-ventricular supports as complete recovery of cardiac function and end-organ damage was observed. The patient was discharged from the intensive care unit after 15 days and discharged home 1 month after presentation. The patient had no further episodes of heart failure at 6 months follow up. Discussion: Prolonged mechanical unloading with two Impella pumps in fulminant COVID-19 myocarditis is a viable and reliable strategy, as it provides the benefits of mechanical circulatory support plus additional disease-modifying effects, reducing wall stress and inflammatory response.

A case of COVID-19-associated fulminant myocarditis successfully treated with mechanical circulatory support.

A 49-year-old man, who had not been vaccinated against COVID-19 visited the hospital for fever and cough, and a PCR test for COVID-19 was positive on the Day X. Initially, there was no decrease in oxygen saturation and the patient was under observation as a mild case without medication. Five days after the onset (Day X + 5), chest pain appeared. Electrocardiogram showed widespread ST-segment elevation, and blood tests showed high levels of troponin I. However, given that there was no stenotic lesion on coronary computed tomography, myocarditis was suspected, and he was transferred to our hospital on the Day X + 6. We started treatment with lemdesivir and dexamethasone. On the Day X + 7, the patient developed decreased left ventricular ejection fraction, hypotension, and hyperlactatemia. We decided that mechanical circulatory support was necessary and an Impella 5.0 was inserted under ventilator management. The patient was successfully weaned from the Impella 5.0 on the Day X + 17, was transferred to the general ward on the Day X + 24, continued rehabilitation, and was discharged home on the Day X + 39 with no heart failure symptoms. In this case, we performed daily bedside echocardiography and chose the Impella 5.0 instead of extra corporeal membrane oxygenation (ECMO) because there were no findings of severe pneumonia or right heart failure. The Impella 5.0 device was inserted via an axillary artery approach, given that it provides more assisted flow than the Impella CP inserted through the inguinal route. Furthermore, early rehabilitation was possible due to the lack of restriction of the lower body.

Characteristics and outcomes of patients presenting with acute myocardial infarction and cardiogenic shock during COVID-19.

OBJECTIVES: To evaluate characteristics and outcomes of patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) during the coronavirus disease 2019 (COVID-19) pandemic. BACKGROUND: The COVID-19 pandemic has created challenges in delivering acute cardiovascular care. Quality measures and outcomes of patients presenting with AMICS during COVID-19 in the United States have not been well described. METHODS: We identified 406 patients from the National Cardiogenic Shock Initiative (NCSI) with AMICS and divided them into those presenting before (N = 346, 5/9/2016-2/29/2020) and those presenting during the COVID-19 pandemic (N = 60, 3/1/2020-11/10/2020). We compared baseline clinical data, admission characteristics, and outcomes. RESULTS: The median age of the cohort was 64 years, and 23.7% of the group was female. There were no significant differences in age, sex, and medical comorbidities between the two groups. Patients presenting during the pandemic were less likely to be Black compared to those presenting prior. Median door to balloon (90 vs. 88 min, p = 0.38), door to support (88 vs. 78 min, p = 0.13), and the onset of shock to support (74 vs. 62 min, p = 0.15) times were not significantly different between the two groups. Patients presented with ST-elevation myocardial infarction more often during the COVID-19 period (95.0% vs. 80.0%, p = 0.005). In adjusted logistic regression models, COVID-19 period did not significantly associate with survival to discharge (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.54-2.19, p = 0.81) or with 1-month survival (OR 0.82, 95% CI 0.42-1.61, p = 0.56). CONCLUSIONS: Care of patients presenting with AMICS has remained robust among hospitals participating in the NCSI during the COVID-19 pandemic.

ECMO and Impella Support Strategies as a Bridge to Surgical Repair of Post-Infarction Ventricular Septal Rupture

Background and Objectives: Post-infarct ventricular septal rupture (PIVSR) continues to have significant morbidity and mortality, despite decreased prevalence. Impella and venoarterial extracorporeal membranous oxygenation (VA-ECMO) have been proposed as strategies to correct hemodynamic derangements and bridge patients to delayed operative repair when success rates are higher. This review places VA-ECMO and Impella support strategies in the context of bridging patients to successful PIVSR repair, with an additional case report of successful bridging with the Impella device. Materials and Methods: We report a case of PIVSR repair utilizing 14 days of Impella support. We additionally conducted a systematic review of contemporary literature to describe the application of VA-ECMO and Impella devices in the pre-operative period prior to surgical PIVSR correction. Expert commentary on the advantages and disadvantages of each of these techniques is provided. Results: We identified 19 studies with 72 patients undergoing VA-ECMO as a bridge to PIVSR repair and 6 studies with 11 patients utilizing an Impella device as a bridge to PIVSR repair. Overall, outcomes in both groups were better than expected from patients who were historically managed with medicine and balloon pump therapy, however there was a significant heterogeneity between studies. Impella provided for excellent left ventricular unloading, but did result in some concerns for reversal of shunting. VA-ECMO resulted in improved end-organ perfusion, but carried increased risks of device-related complications and requirement for additional ventricular unloading. Conclusions: Patients presenting with PIVSR in cardiogenic shock requiring a MCS bridge to definitive surgical repair continue to pose a challenge to the multidisciplinary cardiovascular team as the diverse presentation and management issues require individualized care plans. Both VA-ECMO and the Impella family of devices play a role in the contemporary management of PIVSR and offer distinct advantages and disadvantages depending on the clinical scenario. The limited case numbers reported demonstrate feasibility, safety, and recommendations for optimal management.

Coronavirus disease 2019-associated coronary endotheliitis and thrombotic microangiopathy causing cardiogenic shock: a case report.

Background: Coronavirus disease 2019 (COVID-19) primarily affects the respiratory tract but serious cardiovascular complications have been reported. Up to one-third of patients admitted to the intensive care unit may develop an acute myocardial injury, characterized by cardiac troponin elevation. However, the pathology underlying COVID-19-associated myocardial injury has rarely been reported. Case summary: Three days after being diagnosed for a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, a 52-year-old woman without a notable past medical history developed cardiogenic shock with severely reduced left ventricular ejection fraction (LVEF) at 25%. Coronary angiography was normal. Endomyocardial biopsy demonstrated coronary endotheliitis with multiple microvascular thromboses but no lymphocytic infiltrate and a negative polymerase chain reaction for SARS-CoV-2. The patient was implanted with a short-term LV assist device (Impella CP®, Abiomed, Aachen, Germany) and treated with therapeutic anticoagulation. She suffered from concomitant respiratory failure that required 14 days of orotracheal intubation, 10 days of dexamethasone, and broad-spectrum antibiotics. Clinical outcome was favourable with weaning of the Impella device after 6 days and full recovery of LVEF (65%) at 30 days. Cardiac magnetic resonance performed at Day 30 showed no evidence of myocarditis or scars and confirmed the normalization of LVEF. Discussion: This case highlights how COVID-19-associated coronary endotheliitis and thrombotic microangiopathy, in the absence of myocarditis, may induce transient severe LV dysfunction and cardiogenic shock.

Cardiogenic shock with highly complicated course after influenza A virus infection treated with vva-ECMO and Impella CP (ECMELLA): a case report.

BACKGROUND: The value of mechanical circulatory support (MCS) in cardiogenic shock, especially the combination of the ECMELLA approach (Impella combined with ECMO), remains controversial. CASE PRESENTATION: A previously healthy 33-year-old female patient was submitted to a local emergency department with a flu-like infection and febrile temperatures up to 39 °C. The patient was tested positive for type-A influenza, however negative for SARS-CoV-2. Despite escalated invasive ventilation, refractory hypercapnia (paCO2: 22 kPa) with severe respiratory acidosis (pH: 6.9) and a rising norepinephrine rate occurred within a few hours. Due to a Horovitz-Index < 100, out-of-centre veno-venous extracorporeal membrane oxygenation (vv-ECMO)-implantation was performed. A CT-scan done because of anisocoria revealed an extended dissection of the right vertebral artery. While the initial left ventricular function was normal, echocardiography revealed severe global hypokinesia. After angiographic exclusion of coronary artery stenoses, we geared up LV unloading by additional implantation of an Impella CP and expanded the vv-ECMO to a veno-venous-arterial ECMO (vva-ECMO). Clinically relevant bleeding from the punctured femoral arteries resulted in massive transfusion and was treated by vascular surgery later on. Under continued MCS, LVEF increased to approximately 40% 2 days after the initiation of ECMELLA. After weaning, the Impella CP was explanted at day 5 and the vva-ECMO was removed on day 9, respectively. The patient was discharged in an unaffected neurological condition to rehabilitation 25 days after the initial admission. CONCLUSIONS: This exceptional case exemplifies the importance of aggressive MCS in severe cardiogenic shock, which may be especially promising in younger patients with non-ischaemic cardiomyopathy and potentially reversible causes of cardiogenic shock. This case impressively demonstrates that especially young patients may achieve complete neurological restoration, even though the initial prognosis may appear unfavourable.

Successful use of Impella 5.5 to manage cardiogenic shock complicated by COVID-19.

BACKGROUND: Acute decompensated heart failure in patients with coronavirus disease 2019 (COVID-19) is becoming increasingly common. AIMS: In this case report, we describe the successful use of an Impella 5.5 (Abiomed) to treat cardiogenic shock refractory to inotropic therapy. MATERIALS & METHODS: Transthoracic and transesophageal echocardiography confirmed severely diminished left ventricular ejection fraction and a reverse-transcription polymerase chain reaction test revealed that the patient was COVID-19 positive during his hospital admission. RESULTS: Following initiation of inotropic therapy, we placed an Impella 5.5 for further cardiac support. The patient's LVEF and cardiac index improved after 21 days on the Impella 5.5 and was maintained following explant. DISCUSSION & CONCLUSION: The findings reported here demonstrate successful use of an Impella 5.5 to improve native heart function in refractory cardiogenic shock and further indicate its use as an option for those in acute decompensated heart failure who have tested positive for COVID-19 infection.

Case Report: Lymphohistiocytic Myocarditis With Severe Cardiogenic Shock Requiring Mechanical Cardiocirculatory Support in Multisystem Inflammatory Syndrome Following SARS-CoV-2 Infection.

Multisystem Inflammatory Syndrome (MIS) is a novel hyperinflammatory syndrome associated with SARS-CoV-2 infection. It predominantly affects children (MIS-C) a few weeks after a usually asymptomatic SARS-CoV-2 infection and is only rarely seen in adults above 21 years (MIS-A). Only scarce data on histological findings in both pediatric and adult patients has been published so far. An 18-year-old male patient was admitted to hospital in a febrile state, which progressed to severe cardiogenic shock and multi-organ failure requiring extracorporeal life support. Myocardial biopsy revealed small vessel-associated immune cell infiltrates. Diagnosis of MIS-C was made after ruling out all potential differential diagnosis. Use of immunosuppressive treatment with steroids, interleukin-1 blockade and high-dose intravenous immunoglobulins resulted in the patient's full recovery. Multisystem Inflammatory Syndrome (MIS) is a new differential diagnosis of cardiac dysfunction in pediatric and adult patients. The lack of myocardial necrosis differentiates the disease from other viral myocarditis and offers an explanation for the fast response to immunomodulatory therapy and the favorable prognosis. The preceding SARS-CoV-2 infection might only have been mildly symptomatic or even asymptomatic.

Intracardiac Echocardiography for Point-of-Care Guided Left Ventricular Assist Device Implantation: Surgical Implications for COVID-19.

Data from animal models is now available to initiate assessment of human safety and feasibility of wide-angle three-dimensional intracardiac echocardiography (3D ICE) to guide point-of-care implantation of percutaneous left ventricular assist devices in critical care settings. Assessment of these combined new technologies could be best achieved within a surgical institution with pre-existing expertise in separate utilization of ICE and Impella.

Fatal COVID-19 in a Child with Persistence of SARS-CoV-2 Despite Extensive Multidisciplinary Treatment: A Case Report.

Critical Coronavirus disease 2019 (COVID-19) developed in a 7-year-old girl with a history of dystrophy, microcephaly, and central hypothyroidism. Starting with gastrointestinal symptoms, the patient developed severe myocarditis followed by progressive multiple organ failure complicated by Pseudomonas aeruginosa bloodstream infection. Intensive care treatment consisting of invasive ventilation, drainage of pleural effusion, and high catecholamine therapy could not prevent the progression of heart failure, leading to the implantation of venoarterial extracorporeal life support (VA-ECLS) and additional left ventricle support catheter (Impella® pump). Continuous venovenous hemofiltration (CVVH) and extracorporeal hemadsorption therapy (CytoSorb®) were initiated. Whole exome sequencing revealed a mutation of unknown significance in DExH-BOX helicase 30 (DHX30), a gene encoding a RNA helicase. COVID-19 specific antiviral and immunomodulatory treatment did not lead to viral clearance or control of hyperinflammation resulting in the patient's death on extracorporeal life support-(ECLS)-day 20. This fatal case illustrates the potential severity of pediatric COVID-19 and suggests further evaluation of antiviral treatment strategies and vaccination programs for children.

Remote proctoring for high-risk coronary interventions with mechanical circulatory support during COVID-19 pandemic and beyond.

Remote proctoring by advanced digital technologies may help to overcome pandemic, geographic, and resource-related constraints for mentoring and educating interventional cardiology skills. We present a case series of patients undergoing high-risk percutaneous coronary intervention (HR-PCI) with mechanical circulatory support (MCS) guided by remote proctoring to gain insights into a streaming technology platform with regard to video/audio quality, visibility of all structural and imaging details, and delay in transmission. According to our experience, remote proctoring appears to be a reliable, quick, and resource-conserving way to disseminate, educate and improve MCS-supported HR-PCI with implications far beyond the COVID-19 pandemic.

A case report of a large intracardiac thrombus in a COVID-19 patient managed with percutaneous thrombectomy and right ventricular mechanical circulatory support.

BACKGROUND: The coronavirus disease 2019 (COVID-19) has caused a global pandemic with an unprecedented burden on health and the economy worldwide. Although it primarily involves the respiratory tract system, cardiovascular complications, particularly arterial and venous thrombosis, are frequently reported and are associated with adverse outcomes. CASE SUMMARY: We describe the case of a 57-year-old female who presented with acute hypoxic respiratory failure and shock. She was found to have left lower extremity deep vein thrombosis and a suspected pulmonary embolism. A large mobile right atrial mass was found on echocardiogram. Given the large thrombus burden that portended an extremely high risk for embolization to the pulmonary arteries, emergent percutaneous aspiration of an organized thrombus (rather than thrombolysis) was performed using the AngioVac system (Angiodynamics Inc., Latham, NY, USA) complicated by haemodynamic collapse due to acute right ventricular failure. An Impella RP (Abiomed, Danvers, MA, USA) was then placed, with rapid stabilization of haemodynamics. The patient tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). She was treated with antimicrobial and systemic anticoagulation therapy. She was successfully weaned off the Impella RP on post-operative day 4 and was extubated on day 5. She was discharged on day 16 in a stable condition. DISCUSSION: Incident venous thrombo-embolism is frequently encountered in COVID-19 patients. We report the first case of a large intracardiac thrombus associated with SARS-CoV-2 infection managed successfully with percutaneous thrombectomy and right ventricular mechanical circulatory support.

Impella 5.0 support before, during, and after surgical ventriculoplasty following acute myocardial infarction in the COVID-19 era: a case report.

BACKGROUND: Left ventricular (LV) aneurysms complicate anterior myocardial infarctions (MIs) in 8-15% of cases. In case of associated LV dysfunction, rapidly evolving heart failure may follow, and urgent surgery becomes life-saving. CASE SUMMARY: Following an acute anterior MI treated by percutaneous coronary intervention, which resulted in apical hypokinesis, depressed LV function, and moderate mitral regurgitation, a 70-year-old male patient kept in contact with our cardiology department through phone calls. Over 6 weeks, the patient's conditions worsened. For fear of contracting COVID-19, he refused to attend to the Emergency Room. Conditions did not improve despite medical therapy adjustments, and he was admitted to hospital following a syncope. Computed tomography scan revealed pneumonia, and he was placed in a 'grey' ward while waiting for nose-swab results for COVID-19. A rapid escalation of treatment was necessary as conditions did not improve with low-dose inotropes, and he required invasive ventilation. An Impella 5.0 was implanted as support prior to surgery, was maintained during the procedure and as a means of weaning off extracorporeal circulation. Surgery was successful and Impella 5.0 was removed on postoperative Day 5. DISCUSSION: To date, Impella use in cardiothoracic surgery has been described in case of ventricular septal rupture or as a bridge to permanent LV assist device. In our case, Impella 5.0 was implanted, used as a bridge to surgery, and as postoperative support in a patient with evolving cardiogenic shock due to LV aneurysm and depressed LV ejection fraction following acute MI, in the difficult setting of the COVID-19 pandemic.

Case of Coronavirus Disease 2019 Myocarditis Managed With Biventricular Impella Support.

Severe acute respiratory syndrome coronavirus 2, responsible for coronavirus disease 2019 (COVID-19), is a pandemic that has taken the world by storm. We present the only contemporary reported case of COVID-19 myocarditis leading to recovery with utilization of biventricular Impella (Abiomed, Danvers, MA, USA) for temporary mechanical circulatory support. A 35-year-old female with systemic sclerosis who was found to have five days of generalized malaise associated with fevers and cough. She tested positive for COVID-19 via nasal polymerase chain reaction. Cardiac enzymes were found elevated on admission. Invasive hemodynamics assessment was significant for elevated right and left-sided filling pressures, along with calculated cardiac index of 1.3 L/min/m2. Decision was made to place right and left-sided ventricular support with percutaneous Impella for mechanical circulatory support. She was started on intravenous immunoglobulin for suspected COVID-19 myocarditis along with remdesivir and solumedrol. After two weeks of continuous temporary mechanical circulatory support, the patient's hemodynamics improved and she was discharged. Repeat echocardiogram demonstrated normalization of left ventricular function.

COVID-19 patient with coronary thrombosis supported with ECMO and Impella 5.0 ventricular assist device: a case report.

BACKGROUND: COVID-19 can present with cardiovascular complications. CASE SUMMARY: We present a case report of a 43-year-old previously fit patient who suffered from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection with thrombosis of the coronary arteries causing acute myocardial infarction. These were treated with coronary stenting during which the patient suffered cardiac arrest. He was supported with automated chest compressions followed by peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO). No immediate recovery of the myocardial function was observed and, after insufficient venting of the left ventricle was diagnosed, an Impella 5 pump was implanted. The cardiovascular function recovered sufficiently and ECMO was explanted and inotropic infusions discontinued. Due to SARS-CoV-2 pulmonary infection, hypoxia became resistant to conventional mechanical ventilation and the patient was nursed prone overnight. After initial recovery of respiratory function, the patient received a tracheostomy and was allowed to wake up. Following a short period of agitation his neurological function recovered completely. During the third week of recovery, progressive multisystem dysfunction, possibly related to COVID-19, developed into multiorgan failure, and the patient died. DISCUSSION: We believe that this is the first case report of coronary thrombosis related to COVID-19. Despite the negative outcome in this patient, we suggest that complex patients may in the future benefit from advanced cardiovascular support, and may even be nursed safely in the prone position with Impella devices.