Multisystem Inflammatory Syndrome in Children Requiring ECMO: Anticoagulation strategies and Lessons Learned

Intro: Multisystem Inflammatory Syndrome in Children (MIS-C) is a post-infectious inflammatory response after exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which can cause acute cardiac dysfunction requiring mechanical circulatory support (MCS). MCS utilization for MIS-C is complicated by a propensity for thrombosis, which threatens circuit integrity. This study describes a cohort of MIS-C patients requiring MCS, their outcomes, and the anticoagulation strategies utilized. Method(s): A retrospective case series of patients diagnosed with MIS-C needing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) at Children's Healthcare of Atlanta from March 1, 2020 to June 30, 2022. VA-ECMO variables, laboratory data, complications, and outcomes were collected. Result(s): Seven patients (all male) with severe MIS-C required VA-ECMO for acute cardiac dysfunction. Median age was 13 years (range 4-15 years). Median ICU stay was 13 days (range 6-17 days) with a median ECMO duration of 7 days (IQR 3-8 days) and median mechanical ventilation duration of 8 days (IQR 5-11 days). All seven patients survived to hospital discharge with good neurologic outcomes. Median time to qualitatively normal ventricular function by echocardiogram was 9.5 days (IQR 3-21 days). Heparin was initially used in 6 patients, bivalrudin initially used in 1 patient, and 1 patient converted from heparin to bivalirudin for refractory systemic thrombosis. Median heparin dose was 206u/kg/d (IQR 192-276u/kg/d) with median anti-Xa levels of 0.75 (IQR 0.1-1.1) and median daily PTT 102 seconds (IQR 83-107 seconds). Median daily PTT of patients receiving bivalirudin was 86 seconds (80-93 seconds). Median R-values by thromboelastography were 38 seconds (IQR 25-55 seconds). Two patients required catheter directed thrombolysis with tissue plasminogen activator (t-PA) for refractory intracardiac thrombi, both were initially started on heparin. Significant cannula thrombosis occurred in 2 patients, 1 initially started on heparin and 1 initially on bivalrudin. Bleeding resulting in compartment syndrome occurred in one patient on heparin requiring fasciotomy of the upper extremities, this patient was not receiving t-PA. Conclusion(s): Anticoagulation management for MIS-C patients requiring ECMO is fraught with challenges. A successful management strategy may necessitate higher heparin assay levels, the use of direct thrombin inhibitors for refractory thrombosis, and the deployment of catheter directed thrombolysis. In this case series, CDT was safely and successfully used in two patients. Further studies are required to understand the optimal anticoagulation strategy for these patients to minimize complications.

Trends And Outcomes Of Heart Failure Hospitalizations During Covid 19 Pandemic In California

INTRODUCTION: Coronavirus disease 2019 (COVID-19) has affected hospitalization of cardiac patients, both in terms of number of hospitalizations as well as hospital outcomes. In this study, we intended to understand the effects of COVID-19 pandemic on heart failure hospitalizations in the state of California. HYPOTHESIS: We hypothesized that adverse hospital outcomes such as in-hospital mortality, mechanical ventilation, mechanical circulatory support, vasopressor use, and acute respiratory distress syndrome (ARDS) would be higher among heart failure hospitalizations during 2020, compared to 2019. METHOD(S): The current study was a retrospective analysis of data collected and stored in California State Inpatient Database (SID) during March to December of 2019 and 2020. All adult (>=18 years of age) hospitalizations with heart failure were included for the analysis. ICD-10-CM diagnosis and procedure codes were used for identifying hospitalizations and procedures. We used propensity score matching and conditional logistic regressions to find the association between hospitalizations during 2019 versus 2020 with respect to outcome variables. RESULT(S): There were 101,032 (56.0%) heart failure hospitalizations during March to December of 2019, compared to 79,637 (44.0%) during March to December of 2020 (relative decrease, 21.2%). Hospitalizations for COVID-19 increased from 2,252 to 46,217 during the same period (relative increase, 19521.3%). Adverse hospital outcomes such as in-hospital mortality rates (2.9% versus 2.7%, P=0.003), mechanical ventilation (2.9% versus 2.2%, P<0.001), mechanical circulatory support (0.7% versus 0.5%. P<0.001), vasopressor use (1.3% versus 1.0%, P<0.001), and ARDS (0.1% versus 0.06%, P=0.007) were significantly higher in 2020, compared to 2019. Conditional logistic regression analysis showed that the odds of adverse clinical outcomes such as in hospital mortality (OR, 1.09;95% CI, 1.06-1.11), mechanical ventilation (OR, 1.07;95% CI, 1.05-1.09), vasopressor use (OR, 1.07;95% CI, 1.04-1.10), and ARDS (OR, 1.74;95% CI, 1.58-1.91) were significantly higher among heart failure hospitalizations in 2020. However, the odds of mechanical circulatory support did not differ between the two-time frames. CONCLUSION(S): Our study found that patients with heart failure hospitalized during the COVID-19 pandemic had greater in-hospital adverse events such as greater in-hospital mortality, mechanical ventilation use, vasopressor use, and ARDS. These findings warrant that heart failure requires prompt hospitalization and aggressive treatment irrespective of restrictive mandates during COVID-19 pandemic.Copyright © 2022

A Rare Case Of Eosinophilic Myocarditis Due To Subacute Sars-cov-2 Illness

Background: Eosinophilic myocarditis is a rare inflammatory cardiomyopathy with a poor prognosis. SARS-CoV-2 (COVID-19) illness has been associated with myocarditis, particularly of lymphocytic etiology. Although there have been cases of eosinophilic myocarditis associated with COVID-19 vaccination, there have been few reported cases secondary to COVID-19 illness, with the majority being diagnosed via post-mortem autopsy. Case: A 44-year-old woman with no significant medical history other than recent COVID-19 illness 6 weeks prior presented with progressive dyspnea. Patient developed acute dyspnea and diffuse pruritic rash after taking hydroxyzine. Labs were significant for mild eosinophilia. Echocardiography showed biventricular systolic dysfunction with left ventricular ejection fraction of 40%, and a moderate pericardial effusion that was drained percutaneously. She underwent left heart and right heart catheterization showing elevated biventricular filling pressures, Fick cardiac index of 1.6 L/min/m2, and no coronary disease. She was started on intravenous diuretics and transferred to our facility for further management. Her course was complicated by cardiogenic shock requiring intra-aortic balloon pump (IABP) support. Mixed venous saturations continued to decline and the patient was placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. The patient underwent endomyocardial biopsy (EMB) showing marked interstitial infiltration of eosinophils and macrophages with myocyte injury (see image). She was intubated with mechanical ventilation as well due to worsening pulmonary edema and hypoxemia. She was started on intravenous steroids with improvement of hemodynamics and myocardial function and eventually VA- ECMO was decannulated to low-dose inotropic support which in turn was ultimately weaned after 3 days of mechanical support. Conclusion(s): Eosinophilic myocarditis is a rare and under-recognized sequela of acute COVID-19 infection associated with high mortality rates. It requires prompt diagnosis and aggressive supportive care, including temporary mechanical circulatory support. There are few literature-reported cases of COVID-19 myocarditis requiring use of both IABP and VA-ECMO, none of which were used in biopsy-proven eosinophilic myocarditis, with most of these cases resulting in either fatal or unreported outcomes. Most cases of covid myocarditis required IV glucocorticoids therapy in conjunction with IVIG or interferon therapy. Here, we present a rare case of cardiogenic shock secondary to biopsy-proven eosinophilic myocarditis associated with recent COVID-19 illness with a survival outcome after temporary use of IABP and VA-ECMO support, as well as aggressive immunosuppressive therapy.Copyright © 2022

Year 2022 in review - Cardiac anesthesia and postoperative care.

Cardiac anesthesia and postoperative care in cardiac surgery have their specifics, which differ from other specialties. The last two years marked by the COVID-19 pandemic were associated with a slowdown in elective cardiac surgery. Currently, the number of procedures is increasing again. New drugs are tested, new guidelines are published, innovative and hybrid procedures are performed, with the goal of reducing invasiveness for the patients. The aim of this review is to present readers with the important outputs of publications related to cardiac anesthesia, postoperative care in cardiac surgery, and the use of extracorporeal circulatory support over the past year.Copyright © 2022, Czech Medical Association J.E. Purkyne. All rights reserved.

Myocarditis Following Covid-19 Vaccination In Adolescents And Adults In 2021

Background: Clinical course and outcomes of myocarditis after COVID-19 vaccination remain variable. Method(s): We retrospectively collected data on patients >12 years old from 01/01/2021 to 12/30/2021 who received COVID-19 vaccination and were diagnosed with myocarditis within 60 days of vaccination. Myocarditis cases were based on case definitions by authors. Result(s): We report on 238 patients of whom most were male (n=208;87.1%). The mean age was 27.4 +/- 16 (Range 12-80) years. Females presented at older ages (41.3 +/- 21.5 years) than men 25.7 +/- 14 years (p=0.001). In patients >20 years of age, the mean duration from vaccination to symptoms was 4.8 days +/-5.5 days but in <20, it was 3.0 +/- 3.3 days (p=0.04). Myocarditis occurred most commonly after the Pfizer-BioNTech vaccine;(n=183;76.45) and after the second dose (n=182;80%). Symptoms started 3.95 +/-4.5 days after vaccination. The commonest symptom was chest pain (n=221;93%). Patients were treated with non-steroidal anti-inflammatory drugs (n=105;58.3%), colchicine (n=38;21.1%), or glucocorticoids (n=23;12.7%). About 30% of the patients had left ventricular ejection fraction but more than half recovered on repeat imaging. Abnormal cardiac MRI was common;168 patients (96% of 175 patients that had MRI) had late gadolinium enhancement, while 120 patients (68.5%) had myocardial edema. Heart failure guideline-directed medical therapy use was common (n=27;15%). Eleven patients had a cardiogenic shock, and 4 patients required mechanical circulatory support. Five patients (1.7%) died, of these, 3 patients had endomyocardial biopsy/autopsy-confirmed myocarditis. Conclusion(s): Most cases of COVID-19 vaccine myocarditis are mild. Females presented at older ages than men and the duration from vaccination to symptoms was longer in patients >20 years. Cardiogenic shock requiring mechanical circulatory support was seen and mortality was low. Future studies are needed to better evaluate risk factors and long-term outcomes of COVID-19 vaccine myocarditis.Copyright © 2022

COVID-19 infection in patients with multiple myeloma: A German-Chinese experience from Wurzburg and Wuhan

Currently, experience with COVID-19 in multiple myeloma (MM) is still very limited. Terefore, we conducted this analysis of MM patients infected by COVID-19 from two prominent hematology centers in Wuhan and Wurzburg (Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China and University Hospital of Wurzburg, Wurzburg, Germany) as of 9 June 2020. In total, we identifed fve Caucasian patients from Wurzburg and three Asian patients from Wuhan. The majority of the patients were male (n=5, 63%), and the median age at COVID-19 diagnosis was 57 (range 39-83 years). Tree patients had newly diagnosed (ND) MM, and two of them were therapy naive at diagnosis of COVID-19. One patient from Wuhan was receiving the second cycle of VTD (bortezomib, thalidomide, and dexamethasone) as the first line therapy. In Wuhan, a patient with extramedullary progression (No. 6) received leukapheresis to prepare for a salvage chimeric antigen receptor T-cell (CAR-T) therapy. Due to COVID-19 infection, systemic anti-MM treatment was discontinued in all eight patients. Notably, two patients in Wurzburg showed no COVID-19 symptoms, and the other three patients exhibited only mild symptoms such as fever, cough, and nausea, which did not require an intensive care unit (ICU) admission. Tree patients did not receive any COVID-19 treatment, and all fve patients in Wurzburg recovered. In contrast, two patients from Wuhan developed severe respiratory syndrome so that mechanical ventilation and circulatory support were needed. The patient who was receiving the frontline therapy with VTD also had an elevated procalcitonin value (30.05 ng/ml), suggesting an additional bacterial infection, and this patient died due to acute respiratory failure. In addition, two out of fve patients in our cohort did not show positive IgM or IgG for COVID-19 afer recovery. In summary, our observations showed that COVID-19 infection could be severe especially in NDMM, and also suggested inadequate humoral immune response in MM patients, probably due to secondary immune defciency caused by the treatments or the disease itself. Surprisingly, the MM patients in Wurzburg did not present any signs of severe COVID-19 infection. Other than Wuhan where COVID-19 was reported for the first time, in Europe, the pandemic had already been announced, and in Germany the lock-down came relatively early in comparison to other countries.

Admissions to the Pediatric Icu Associated with Coronavirus 2 Disease (Sars-Cov-2) in a Pediatric Reference Hospital in Ecuador

BACKGROUND AND AIM: Multisystem inflammatory syndrome in children (MIS-C) has been associated with SARS-CoV-2 infection in pediatric population treated at Pediatric Intensive Care Unit (PICU). To compare patients with pediatric acute respiratory distress syndrome (PARDS) with those who also presented a diagnosis of MIS-C. METHOD(S): Retrospective cohort study with 167 patients admitted to the PICU Covid-19 at Baca Ortiz Pediatric Hospital (BOPH) located in Quito, Ecuador from June 2020 - June 2021, who developed PARDS with or without MIS-C. We performed a logistic regression analysis to calculated Odds Ratios (OR) with 95% CI. RESULT(S): Of the 167 patients, PCR test was positive in 20.1%. 58.7% of the study population developed MIS-C. This was associated with respiratory bacterial coinfection (OR: 3.63 [95% CI: 1.81-7.29]), circulatory support (OR: 38.8 [11.2-134.6]), acute renal failure (OR: 6.09 [2.4-15.5]), septic shock (OR: 89.9 [28.5-283.9]), coronary dilatation (OR: 3.79 [1.45-9.8]);multi-organ failure (OR: 44.9 [5.99- 337.3]), death (OR: 14.5 [4.27-49.5]). Further, a severe inflammatory state and high risk of sepsis were present as shown by an elevated D-dimer (OR: 6.53 [2.06-20.7]);total CPK (6.96 [3.5-13.9]);and procalcitonin (OR: 10.5 [5.06- 21.8]). Treatment in the MIS-C group included antibiotics (100%), corticoids (79.5%), immunoglobulin (IV) (86.4%), and ventilatory support (11.5 +/- 12.6 days). CONCLUSION(S): The MIS-C associated with Covid-19 produced a more severe condition, as a result of a dysregulated inflammatory state;which resulted in failure of various organ systems and high mortality in the PICU. This was evidenced by the clinical and analytical profile and the treatments used.

Prevalence Characteristics and Outcomes of Covid 19 Associated Acute Myocarditis

Background: Acute myocarditis (AM) is thought to be a rare cardiovascular complication of COVID-19, although minimal data are available beyond case reports. We aim to report the prevalence, baseline characteristics, in-hospital management, and outcomes for patients with COVID-19-associated AM on the basis of a retrospective cohort from 23 hospitals in the United States and Europe. Method(s): A total of 112 patients with suspected AM from 56963 hospitalized patients with COVID-19 were evaluated between February 1, 2020, and April 30, 2021. Inclusion criteria were hospitalization for COVID-19 and a diagnosis of AM on the basis of endomyocardial biopsy or increased troponin level plus typical signs of AM on cardiac magnetic resonance imaging. We identified 97 patients with possible AM, and among them, 54 patients with definite/probable AM supported by endomyocardial biopsy in 17 (31.5%) patients or magnetic resonance imaging in 50 (92.6%). We analyzed patient characteristics, treatments, and outcomes among all COVID-19-associated AM. Result(s): AM prevalence among hospitalized patients with COVID-19 was 2.4 per 1000 hospitalizations considering definite/probable and 4.1 per 1000 considering also possible AM. The median age of definite/probable cases was 38 years, and 38.9% were female. On admission, chest pain and dyspnea were the most frequent symptoms (55.5% and 53.7%, respectively). Thirty-one cases (57.4%) occurred in the absence of COVID-19-associated pneumonia. Twenty- one (38.9%) had a fulminant presentation requiring inotropic support or temporary mechanical circulatory support. The composite of in-hospital mortality or temporary mechanical circulatory support occurred in 20.4%. At 120 days, estimated mortality was 6.6%, 15.1% in patients with associated pneumonia versus 0% in patients without pneumonia (P=0.044). During hospitalization, left ventricular ejection fraction, assessed by echocardiography, improved from a median of 40% on admission to 55% at discharge (n=47;P<0.0001) similarly in patients with or without pneumonia. Corticosteroids were frequently administered (55.5%). Conclusion(s): AM occurrence is estimated between 2.4 and 4.1 out of 1000 patients hospitalized for COVID-19. The majority of AM occurs in the absence of pneumonia and is often complicated by hemodynamic instability. AM is a rare complication in patients hospitalized for COVID-19, with an outcome that differs on the basis of the presence of concomitant pneumonia.

A Review of Cardiovascular Complications among Pregnant Patients with COVID-19

Cardiovascular complications of severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection are well-described in the general population but remain limited among pregnant patients. This review summarizes data from case reports, case series, and observational studies of cardiovascular manifestations of corona virus disease 2019 (COVID-19) in pregnant patients and provides recommendations to the cardiovascular clinician regarding management considerations in this vulnerable population. Pregna is an immunocompromised state in which cardiovascular demands are increased. Cardiovascular complications of COVID-19 that have been described in pregnancy include myocardial injury, cardiomyopathy, thromboembolism, pre-eclampsia and arrhythmia. Physiologic and cardiovascular changes in pregnancy predispose pregnant patients with COVID-19 to more severe illness than the general population. Black or Hispanic race, obesity, diabetes, hypertension and lung disease are risk factors for more severe infection, maternal death and adverse perinatal outcomes. Pregnant patients with severe COVID-19 disease compared with non-pregnant age-matched women with COVID infection are more likely to be admitted to the intensive care unit (ICU), receive mechanical ventilation and require advanced mechanical circulatory support. Cardiovascular complications of COVID-19 in pregnant patients requires further attention, particularly given the anticipated increase in birth volume and ongoing nature of COVID-19 pandemic with novel variants. Clinicians should have a lower threshold for cardiac testing and multidisciplinary management in pregnant women with severe COVID-19 disease. Given the persistence of COVID-19 within our communities, diagnostic laboratory and imaging testing for high-risk pregnant patients hospitalized with COVID-19 infection should be routine. We strongly urge the implementation of a cardio-obstetric multidisciplinary team in individually managing these high-risk patients in an effort to improve maternal and fetal outcomes. Copyright: © 2022 The Author(s).

Clinical characteristics and outcome of hospitalized children and adolescent patients with type 1 diabetes during the second wave of COVID-19 pandemic

Introduction: It is unclear whether diabetes alone contributes to increased risk of morbidity and mortality related to COVID-19. Objective(s): This study aimed to explore the relationship between diabetes and the severity of COVID-19 infection as well as the impact of COVID-19 on the clinical presentation and outcome in patients with type 1 diabetes. Method(s): This cross sectional study included 51 children and adolescents with type 1 diabetes mellitus (T1DM) attending the Pediatric Hospital. Participants included all patients with type 1 diabetes admitted to Children's Hospital, Ain Shams University in the period between August and December 2020. Data of studied patients was extracted from inpatient files and reports. Result(s): The age of the patients ranged from 1-17 years with median of 9 (6-13) years, with female predominance [27 (52.9%)]. A 45 presented in DKA, with mean pH of 7.04 +/- 0.29. The median duration of hospital admission was 4 (2-7) days. A 33 patients were newly diagnosed and presented in DKA except 5 (15.2%) patient that presented in hyperglycemia. The mean HbA1c was 11.70 +/- 1.86, the median time till hospital admission was 1.5 (1-2) days. Acute kidney injury (AKI) and echocardiographic changes were reported in 12 (36.4%) and 4 patients 4 (12.1%) respectively. All patients with AKI were admitted to ICU, all showed significantly lower PH at presentation, HCO3 level, and serum albumin level (p < 0.05). Although 22 patients had COVID infection either by PCR or antibodies, only six patient required respiratory support, 13 patients required circulatory support and 6 had echo changes. Two patients had manifestation of MIS-C and required ICU admission and anticoagulants. Conclusion(s): COVID infection in diabetic patients was associated with sever presentation of DKA and multiple organ affection, which could be related to viral affection or delayed hospital admission during the pandemic.

Acute myocarditis in children: Features and outcomes of COVID-19 and NON-COVID patients

Background and Aim: The objective of the study was to assess the features of acute myocarditis and compare Covid19 and non-Covid19 cases. Method(s): Patients lt;18y with acute myocarditis (proved by virology and/or MRI and/or complete recovery of myocardial function) were included. Clinical data, echocardiographic parameters and outcomes were collected. Cases were divided in groups I (non-Covid), II (Covid). Result(s): From 1983 to 2021, 139 patients were included: 76 patients in group I and 63 in group II, 67males (31 in group I = 40% vs 36 in II = 57%). Mean age at diagnosis was 6.8 years: 4.2 years in group I vs 9.9 years in II. Heart failure (HF) was present at onset in 78% of cases in group I and 50% in group II: severe HF was more frequent in group I, chest pain was more frequent in II. Mean left ventricular shortening fraction (LVSF) at diagnosis was 23.8%: 18.4% in groups I vs 31.6% in II (plt;0.05). Mitral regurgi-tation was present in 63.8% of cases = 76.5% vs 43.8% respectively in groups I and II, pericarditis in 16.4% (no difference between groups), thromboembolic events occurred in 7% and arrhythmias in 10% ((all in group I). Virus was positive in 37.5% in group I and SARS-Cov2 positive in all of group II. Inotrope support was needed in 47%, mechanical circulatory support in 8% in group I only. Eleven patients died in group I, no death occurred in group II. One was transplanted(3rdmonth) and 19 have sequellae in group I. Complete recovery occurred in 74% of all cases: 40 of group I (58%) and all of group II (100%): time to recovery was longer in group I (2 years) than in group I (2 weeks). Mean LVSF improved from 18.4% at onset, to 24.6% at 1st month, 26.5% at 3rd month, 30.7% at 6th month and 38% at last FU in group I, while mean LVSF normalized within 2 weeks after onset in group II. Conclusion(s): Myocardial dysfunction and heart failure were less fre-quent, and complete recovery occurred promptly in COVID cases, while myocardial improvement progressed slowly within first 6months and beyond in half of non-COVID cases.

CIRCULATING DAMAGE-ASSOCIATED MOLECULAR PATTERNS (DAMPS) AS PROGNOSTIC MARKERS OF DISEASE SEVERITY IN PATIENTS WITH COVID-19 ARDS IN THE ICU

SESSION TITLE: Biological Markers in Patients with COVID-19 Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Pandemic SARS-CoV-2 infection (COVID-19), like other respiratory viruses, caused a massive incidence of acute respiratory distress syndrome (ARDS). Prior literature showed that influenza infection results in a significant increase in the level of circulating High Mobility Group Box 1 (HMGB1) in infected mice, cotton rats, and in humans;and a small molecule inhibitor of HMGB1 blocked lung pathology and lethality in influenza-infected mice and cotton rats. Moreover, HMGB1 has also been shown to be elevated in the serum of patients with ARDS and is an indicator of increased mortality. Gastrin Releasing Peptide (GRP) has been implicated in bronchopulmonary dysplasia, chronic obstructive pulmonary disease, chronic bronchitis, emphysema, and fibrosis. In addition to HMGB1, GRP represents a novel DAMP that, when targeted therapeutically in influenza-infected mice, is highly protective. The interaction between GRP and HMGB1 is currently under study. We examined if these DAMPS are associated with poor clinical outcomes in patients with COVID-19 ARDS. METHODS: Deidentified patient plasma and serum samples were obtained from discarded, clinical blood samples from 100 patients with COVID-19 admitted to UMMC's intensive care unit (ICU). Demographic and clinical data were collected from the patient’s electronic medical record. HMGB1 and GRP ELISA kits were used to analyze their concentrations in patients’ sera at Day 1 of admission to ICU. Cox proportional hazards models were used to examine the relationship between risk factors and severity of hypoxemia (P/F ratio), need for mechanical ventilation, and need for mechanical circulatory support (VV-ECMO). RESULTS: The average age of study participants was 59.1 years of which 59.2% were men and 57.1% were African American. The mean BMI was 34.3 kg/m2. The prevalence of hypertension, hyperlipidemia, diabetes, pulmonary and cardiovascular disease was 57.1%, 26.5%, 42.9%, 32.7%, and 42.9%, respectively. We found that GRP concentration was associated with worsening hypoxemia (mild 31.9, mod. 42.7, severe 79.0 ng/ml;p=0.014), requirement for mechanical ventilation (No 40.1, Yes 61.5 ng/ml;p=0.063), and need for VV-ECMO (No 48.6, Yes 93.1 ng/ml;p=0.026). HMGB1 concentration was associated with worsening hypoxemia (mild 24.4, mod. 55.1, severe 40.9 ng/ml;p=0.021) but did not correlate with other outcomes. CONCLUSIONS: GRP and HMGB1 have been previously implicated in the pathogenesis of viral infections, such as influenza, and ARDS in animal models and human. Our results suggest that these DAMPs maybe associated with severity of disease in critically ill patients with COVID-19 infection. CLINICAL IMPLICATIONS: Future studies should elucidate the specific cellular and biochemical pathways implicated in pathogenesis of ARDS, identify whether HMGB1 and GRP could be potential biomarkers for severe illness outcomes, and test novel anti-HMGB1 and GRP therapeutics in ARDS. DISCLOSURES: No relevant relationships by Fahid Alghanim no disclosure on file for Jeffrey Hasday;Consultant relationship with Guidepoint Please note: $1-$1000 by Carl Shanholtz, value=Consulting fee stock holder relationship with Teva Pharmaceuticals Please note: $1001 - $5000 by Carl Shanholtz, value=stock iinvestor relationship with illumina Please note: $1001 - $5000 by Carl Shanholtz, value=options No relevant relationships by Kari Ann Shirey No relevant relationships by Mohan Tulapurkar No relevant relationships by Stefanie Vogel

RAPIDLY PROGRESSIVE PERIMYOCARDITIS IN SARS-COV-2 INFECTION

SESSION TITLE: Extraordinary Cardiovascular Reports SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: The COVID-19 pandemic has resulted in millions of deaths worldwide. Many cases involved a primary pulmonary process, yet myocarditis associated with COVID-19 has been observed.1 We present a novel case of rapidly progressive fulminant peri-myocarditis with minimal lung involvement in acute COVID-19 infection. CASE PRESENTATION: A 39-year-old female with no medical history presented with chest pain and dyspnea with an acute COVID-19 infection. She had a brief cardiac arrest with rapid ROSC and no intubation. Chest CT angiogram showed essentially normal pulmonary parenchyma and moderate pericardial effusion. EKG showed sinus tachycardia with global ST segment elevation. An echocardiogram showed an ejection fraction (EF) of 25% with a moderate sized pericardial effusion and right ventricle collapse. She was transferred for emergent drainage of the effusion to our institution. Her circulatory shock initially improved following pericardial drainage, yet she declined warranting increasing vasopressor and inotropic support. An emergent echo showed an EF of less than 10% and no re-accumulation of pericardial fluid. It was clear that the patient required mechanical circulatory support (MCS) and was transferred to the catheterization lab. While in the lab, the patient suffered cardiac arrest and an Impella device was placed during prolonged ACLS without achieving ROSC. Venoarterial ECMO cannulation was then performed. She was transferred to a cardiac transplant center where she later developed multi-organ failure leading to death. DISCUSSION: While COVID-19 has been shown to affect multiple organs apart from the lungs, this case was notable due to minimal pulmonary involvement. The patient's manifestation of her infection was almost entirely cardiac in nature. MCS was discussed in the catheterization lab at the time of pericardial drain insertion. The decision was made to not pursue MCS as the patient's shock had improved. Additionally, the patient did not undergo pulmonary arterial catheter (PAC) placement. Prompt placement of a PAC has been associated with early access to MCS and reduced in-hospital mortality.2 Perhaps we would have obtained MCS earlier if PAC data supported this intervention before the patient deteriorated. It will be important to consider primary cardiac manifestations of COVID-19 infection and early consideration of invasive hemodynamic monitoring to identify a need for timely MCS. CONCLUSIONS: We present the first reported case of fulminant peri-myocarditis in the absence of acute hypoxemic respiratory failure or radiographic pulmonary parenchymal lung abnormality. Isolated rapidly progressive cardiogenic shock secondary to COVID-19 associated peri-myocarditis is a phenomenon important for critical care clinicians to be aware of during this pandemic. One should have a low threshold to establish invasive hemodynamic monitoring and consideration for early MCS in these cases. Reference #1: Siripanthong B, Nazarian S, Muser D, et al. Recognizing COVID-19-related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management. doi:10.1016/j.hrthm.2020.05.001 Reference #2: Osman M, Syed M, Patel B, et al. Invasive Hemodynamic Monitoring in Cardiogenic Shock Is Associated With Lower In-Hospital Mortality. Journal of the American Heart Association J Am Heart Assoc. 2021;10:21808. doi:10.1161/JAHA.121.021808 DISCLOSURES: No relevant relationships by Samuel Bullick No relevant relationships by Jonathan Greenberg No relevant relationships by Scott Slusarenko

BETA BLOCKER AND CALCIUM CHANNEL BLOCKER OVERDOSE COMPLICATED BY COVID-19 PNEUMONIA AND RENAL FAILURE IN A PATIENT WITH SEVERE OBESITY

SESSION TITLE: A Look Into Poisoning and Drug Overdoses SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: We present a case of a 64-year-old woman with severe obesity (BMI 53) who presented with shock after beta-blocker (BB) and calcium channel-blocker (CCB) overdose. CASE PRESENTATION: The patient presented after an intentional suicide attempt, taking multiple antihypertensive medications, including tablets of nifedipine 90mg, carvedilol 25mg, and losartan 100mg. She had also been experiencing shortness of breath and lower extremity pain for several days. Upon arrival, she was lethargic and minimally responsive, and was found to be in shock with a heart rate 63. She was intubated for airway protection and started on multiple vasopressors including norepinephrine, phenylephrine, vasopressin, dopamine and epinephrine for circulatory support. She was also found to be positive for SARS-CoV-2. She was given activated charcoal, received gastric lavage, and whole bowel irrigation. She received a bolus of regular insulin at 1U/kg, and subsequently started on a high-dose insulin infusion titrated to 11U/kg/h along with dextrose infusion and calcium gluconate. By day four of admission, vasopressor requirements had been reduced to only norepinephrine and the insulin infusion had been successfully discontinued. However, her hospital course was further complicated MRSA and Pseudomonas pneumonia, and renal failure requiring hemodialysis. She continued to develop refractory shock, and remained over 50 liters net positive. Her condition progressively deteriorated and her gross volume overload was difficult to manage, and ultimately expired on day ten of admission. DISCUSSION: The management of CCB and BB overdose has been studied, with hyperinsulinemic euglycemic therapy (HIET)1,2 as our choice. Our patient's decline was likely secondary to the high volumes of dextrose infusion required after HIET. With underlying renal failure, insulin clearance proved to be a significant challenge. Such severe obesity with a weight-based regimen resulted in over 1500U insulin/hr at any given point with our patient. Renal clearance is governed by a proportion of t/V, where t denotes length of a dialysis session and V the volume of fluid in the patient's body.3 Patients with significant volume would require extensive dialysis sessions and fluid balances would be challenging. Continuous renal replacement therapy (CRRT) was attempted later in her hospital course. However, the patient was not able to tolerate it as she had progressed to multiorgan failure. CONCLUSIONS: HIET has shown to be a successful management strategy for CCB and BB overdose. However, weight-based dosing can prove to be a challenge in patients with severe obesity. CRRT should be considered early in severely obese patients that undergo HIET, given the rapid accumulation of fluid secondary to the large-volume insulin and dextrose infusions. Further investigations should look into identifying maximal safe dosages of HIET, especially in severely obese patients. Reference #1: Cole JB, Arens AM, Laes JR, Klein LR, Bangh SA, Olives TD. High dose insulin for beta-blocker and calcium channel-blocker poisoning. Am J Emerg Med. 2018 Oct;36(10):1817-1824. doi: 10.1016/j.ajem.2018.02.004 Reference #2: Krenz JR, Kaakeh Y. An Overview of Hyperinsulinemic-Euglycemic Therapy in Calcium Channel Blocker and β-blocker Overdose. Pharmacotherapy. 2018 Nov;38(11):1130-1142. doi: 10.1002/phar.2177 Reference #3: Turgut F, Abdel-Rahman E, M: Challenges Associated with Managing End-Stage Renal Disease in Extremely Morbid Obese Patients: Case Series and Literature Review. Nephron 2017;137:172-177. doi: 10.1159/000479118 DISCLOSURES: No relevant relationships by Alejandro Garcia No relevant relationships by Vishad Sheth no disclosure on file for Andre Sotelo;

Outcomes in Extracorporeal Membrane Oxygenation (ECMO) singlecenter experience in Latin America

Introduction: Extracorporeal membrane oxygenation (ECMO) provides advanced cardiopulmonary circulatory support for patients with cardiac and/or respiratory failure. There is an incremental use of ECMO in Latin America in the last years, given recent data on its beneficial effect on cardiogenic shock and also because of the lack of other ventricular assist devices. Method(s): Retrospective analyses of all patients who were supported with Extracorporeal Membrane Oxygenation (ECMO) at a tertiary care institution in Mexico City from January 2014 until March 2022. Result(s): A total of 53 patients were treated with ECMO support, 39 (73.5%) with veno-arterial (VA) ECMO and 14 (26.4%) with veno-venous ECMO. The median patient age was 41.8 and 37 patients were male. Primary ECMO indications were cardiogenic shock (42, 79.2%), acute respiratory distress syndrome related to COVID-19 infection (8, 15%), high-risk TAVI (1, 1.8%), cardiac arrhythmia ablation (1, 1.8%), respiratory failure secondary to pulmonary thromboendarterectomy (1,1.8%). For the case of cardiogenic shock causes, there were divided as follows postcardiotomy (23), post-myocardial infarction (10), myocarditis (3), Takotsubo cardiomyopathy (1), pulmonary thromboendarterectomy and cardiogenic shock (5) (Image). The overall mortality rate of our study was 52.8%. Conclusion(s): Extracorporeal membrane oxygenation is an effective therapy growing in use in our country, provides a therapy that is beneficial for a wide spectrum of diseases. Our study revealed a similar mortality rate according to international registries. Given the lack of other circulatory support devices in our region more efforts are needed in order to expand ECMO therapy.

Design of a Simulator for Ventricular Assistance Devices

Recent research shows that the number of patients with heart disease is still bigger than Covid 19 disease. Some indicators in Brazil indicate about 400,000 deaths per year. Because of heart disease, heart failure is responsible for the main cause of hospitalization of patients over 65 years of age. Part of these patients eventually developed one or more severe disease because of heart disease, leaving as clinical alternatives, treatments, and more aggressive procedures such as heart transplantation. The current scenario for patients waiting for a heart transplantation is actually aggravated each day by the pandemic. Other problem is the organ rejection that is 15% of mortality rate. Then a clinical alternative that can provide support and improve the life quality of patients with heart failure is the mechanical circulatory assistance devices. This kind of device is aiding and/or substitutes in cardiovascular function and it is recognized by the medicine showing satisfactory results over the years. However, the homologation of this kind of device to clinical use is hard and these devices need to be submitted to exhaustive tests, in distinct phases. “In Vitro” validations are applied, a test performed in simulators, whether they physical, computational or hybrid and “In Vivo”, a test that is performed on animals. After these validations, clinical evaluations are started for equipment approval. In this context, the objective of this work is to present the design, construction and functioning of a physical fluid dynamic simulator, which allows testing in ventricular assist devices, with the ability to reproduce the variations of systolic and diastolic blood pressure, as well as the other phenomena related to the functioning of the cardiovascular system. For the project, we used a review of the historical line of the simulators, concepts of hydraulics, anatomy of the human cardiovascular system, heart diseases and PID control algorithms from the theoretical basis. The construction of the physical plant is finished and some tests are made presenting excellent results. The simulator is equipped with two tanks, one proportional control valves, recirculation systems, two level control sensors, blood flow meters, an Microcontroller with a PID control algorithm and a man machine interface developed in android platform. The tests demonstrated the full functioning of the simulator, with the automatic stabilization of the levels, pressure and flow. The tests were made based on the patient body conditions and the variation parameters were observed of the ventricular assist device response. Then the some heart disease were simulated with the modulation of the valve and the monitoring of the ventricular assist device flow as a function of the setpoint change, all these parameters inserted and monitored through a cellular application. (Figure Presented).

Mechanical Circulatory Support for Multisystem Inflammatory Syndrome in Children (MIS-C): A Single Center Case Series

Purpose: Multisystem inflammatory syndrome in children (MIS-C) is a rare but life-threatening complication of SARS-CoV-2 that is characterized by a hyperinflammatory state leading to multiorgan dysfunction. With prompt initiation of appropriate medical management, patients fair well with resolution of the hyperinflammatory state and recovery of end-organ function. However, a small subset of patients with MIS-C develop progressive end-organ dysfunction necessitating mechanical circulatory support (MCS). This case series describes a single center experience of MCS for MIS-C. Methods: This is a retrospective case series of patients diagnosed with MIS-C who required MCS between May 2020-February 2022 at Texas Children's Hospital. The study was conducted under institutional review board approval. Results: During the study period, 291 patients were diagnosed with MISC. Of those, 6 required MCS: 4 were placed on VAECMO with 1 patient additionally requiring a left ventricular assist device (LVAD), 1 required solely LVAD support, and 1 required VV-ECMO in the setting of pulmonary hemorrhage. In 5 of the 6 patients, the primary indication for MCS was a hemodynamically significant tachyarrythmia. Echocardiography showed worsening of global longitudinal strain (GLS) prior to cannulation in those patients in which it was measured. 5 of the 6 patients survived to hospital discharge. 2 patients required emergent fasciotomies and subsequent limb amputation. Immunomodulation with anakinra before MCS correlated with shorter intensive care length of stay. Outpatient follow-up was conducted in the MIS-C clinic, ranging from 1 to 15 months since discharge, with notable normalization of cardiac function and no additional adverse events. Conclusion: Overall, the need for MCS in patients diagnosed with MIS-C is uncommon and outcomes seem favorable. The development of tachyarrhythmias and worsening GLS may be risk factors for MCS. These findings need to be validated with larger, multicenter studies. Prospective studies of early therapeutic intervention in MIS-C are also needed.

Platelet Function at the Intersection of the COVID-19 “Cytokine Storm” and Mechanical Circulatory Support

Purpose: Release and circulation of pro-inflammatory cytokines or “cytokine storm,” a pathophysiologic component of severe COVID-19, is associated with thrombosis and clot embolization. Compromised patients often require extracorporeal oxygenation and mechanical circulatory support (MCS), imparting blood flow disturbances and exogenous shear stress, further amplifying thrombotic potential. Central in these processes is the platelet. The dynamic interaction of MCS flow/shear and inflammatory cytokines and their propensity for altering platelet function remains unknown. We hypothesized that platelet function is modified in an MCS + pro-inflammatory cytokine environment. We examined platelet aggregation as a function of time, exposing platelets to COVID-19-associated cytokines under MCS flow in vitro. Methods: An Impella5.5® was affixed in a closed loop and positioned with outflow cannula in a 1-inch tube region, maintained at differential 60mmHg pressure. Alternatively, a CentriMag® was affixed in series with a similar closed loop. Porcine PRP, obtained via centrifugation of fresh, ACD-A anticoagulated whole blood was used as circulating fluid. A cytokine “COVID cocktail” of porcine IL-6 (4.5 ng/mL), IL-1β (0.5 ng/mL), IL-8 (2.7 ng/mL), and TNFα (1 ng/mL) was added to PRP and circulated at 5 L/ min. After 5, 60 and 240min of circulation, platelet samples were taken and measured for aggregation with ADP (20uM), and expression of activation markers (CD62P, AnnV) via flow cytometry. Samples were measured in duplicate from N ≥ 2 pigs per experiment. Results: The addition of COVID Cocktail cytokines led to an increase in overall aggregability of platelets over time. In contrast, the addition of shear via MCS devices led to a decrease in platelet aggregability despite Cytokine addition (Fig 1). Notably, platelet aggregability was more greatly reduced with CentriMag (85% reduction) than with Impella (65% reduction). There was no significant difference in platelet activation (AnnV binding, CD62P exposure) between CentriMag and Impella 5.5 in the cytokine environment. (Figure Presented).