Impact of time to diagnosis on the occurrence of cardiogenic shock in MIS-C post-COVID-19 infection.

BACKGROUND: In multisystem inflammatory syndrome in children (MIS-C), diagnostic delay could be associated with severity. This study aims to measure the time to diagnosis in MIS-C, assess its impact on the occurrence of cardiogenic shock, and specify its determinants. METHODS: A single-center prospective cohort observational study was conducted between May 2020 and July 2022 at a tertiary care hospital. Children meeting the World Health Organization MIS-C criteria were included. A long time to diagnosis was defined as six days or more. Data on time to diagnosis were collected by two independent physicians. The primary outcome was the occurrence of cardiogenic shock. Logistic regression and receiver operating characteristic curve analysis were used for outcomes, and a Cox proportional hazards model was used for determinants. RESULTS: Totally 60 children were assessed for inclusion, and 31 were finally analyzed [52% males, median age 8.8 (5.7-10.7) years]. The median time to diagnosis was 5.3 (4.2-6.2) days. In univariable analysis, age above the median, time to diagnosis, high C-reactive protein, and high N-terminal pro-B-type natriuretic peptide (NT-proBNP) were associated with cardiogenic shock [odds ratio (OR) 6.13 (1.02-36.9), 2.79 (1.15-6.74), 2.08 (1.05-4.12), and 1.70 (1.04-2.78), respectively]. In multivariable analysis, time to diagnosis ≥ 6 days was associated with cardiogenic shock [adjusted OR (aOR) 21.2 (1.98-227)]. Time to diagnosis ≥ 6 days had a sensitivity of 89% and a specificity of 77% in predicting cardiogenic shock; the addition of age > 8 years and NT-proBNP at diagnosis ≥ 11,254 ng/L increased the specificity to 91%. Independent determinants of short time to diagnosis were age < 8.8 years [aHR 0.34 (0.13-0.88)], short distance to tertiary care hospital [aHR 0.27 (0.08-0.92)], and the late period of the COVID-19 pandemic [aHR 2.48 (1.05-5.85)]. CONCLUSIONS: Time to diagnosis ≥ 6 days was independently associated with cardiogenic shock in MIS-C. Early diagnosis and treatment are crucial to avoid the use of inotropes and limit morbidity, especially in older children.

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.

Acute Perimyocarditis - an ST-Elevation Myocardial Infarction Mimicker: A Case Report.

BACKGROUND A normal coronary angiogram in ST-elevation myocardial infarction (STEMI) can be considered a myocardial infarction with non-obstructive coronary arteries (MINOCA) until an alternative diagnosis is obtained. However, the COVID-19 pandemic might delay urgent coronary angiography in a resource-limited setting. Perimyocarditis often causes symptoms, such as chest pain, as well as ST-elevation and high cardiac troponin levels. This STEMI mimicker can also cause cardiogenic shock and death when not treated properly. CASE REPORT A 40-year-old man reported having acute onset of substernal chest pain, which was suspected to be STEMI. The patient was an active smoker without any risk factors or a history of cardiovascular disease. The examination showed elevated cardiac troponin I, ST-elevation in high lateral leads, and regional wall motion abnormality (RWMA) by echocardiogram. Furthermore, thrombolytic therapy had failed, and rescue percutaneous coronary intervention was not performed due to the catheterization laboratory limitation during the COVID-19 pandemic. Before coronary angiography, the patient was scheduled for 2 consecutive days of COVID-19 polymerase chain reaction (PCR) swabs. On the second day of hospitalization, the patient experienced a cardiogenic shock. The COVID-19 PCR results were negative, while coronary angiography revealed normal coronary arteries. The patient was eventually diagnosed with probable acute perimyocarditis. CONCLUSIONS Myocarditis is implicated in young patients without typical cardiovascular risk factors or in those with recent infection and cardiovascular symptoms mimicking acute coronary syndrome. It might also be present in situations where ST-elevation distribution on the electrocardiogram is discordant with the RWMA observed on the echocardiogram.

Refractory Cardiogenic Shock Secondary to Acute Myocarditis in a Child with Multisystem Inflammatory Syndrome Associated with COVID-19: A Case Report.

Children with Coronavirus disease 2019 infection usually have mild symptoms but rarely may present with a life-threatening condition called a multisystem inflammatory syndrome. We report a case of COVID-19-related multisystem inflammatory syndrome in an 8-year-old boy who presented with cardiogenic shock due to acute myocarditis with no features of Kawasaki disease. Cardiogenic shock was refractory to fluids and inotropes. Later, this case was successfully managed with hydrocortisone and intravenous immunoglobulin. Therefore, this case report highlights keeping a lookout for such atypical presentations and early referral to a higher center for timely intervention and aggressive therapy specifically directed against the underlying inflammatory process to ameliorate the outcomes. Keywords: cardiogenic shock; COVID-19; kawasaki disease; myocarditis; Nepal.

Angiographic and clinical outcome of SARS-CoV-2 positive patients with ST-segment elevation myocardial infarction undergoing primary angioplasty: A collaborative, individual patient data meta-analysis of six registry-based studies.

BACKGROUND: The characteristics and outcome of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive patients with ST-Elevation Myocardial Infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) are still poorly known. METHODS: The PANDEMIC study was an investigator-initiated, collaborative, individual patient data (IPD) meta-analysis of registry-based studies. MEDLINE, ScienceDirect, Web of Sciences, and SCOPUS were searched to identify all registry-based studies describing the characteristics and outcome of SARS-CoV-2-positive STEMI patients undergoing PPCI. The control group consisted of SARS-CoV-2-negative STEMI patients undergoing PPCI in the same time period from the ISACS-STEMI COVID 19 registry. The primary outcome was in-hospital mortality; the secondary outcome was postprocedural reperfusion assessed by TIMI flow. RESULTS: Of 8 registry-based studies identified, IPD were obtained from 6 studies including 941 SARS-CoV-2-positive patients; the control group included 2005 SARS-CoV-2-negative patients. SARS-CoV-2-positive patients showed a significantly higher in-hospital mortality (p < 0.001) and worse postprocedural TIMI flow (<3, p < 0.001) compared with SARS-CoV-2-negative subjects. The increased risk for SARS-CoV-2-positive patients was significantly higher in males compared to females for both the primary (p_interaction = 0.001) and secondary outcome (p_interaction = 0.023). In SARS-CoV-2-positive patients, age ≥ 75 years (OR = 5.72; 95%CI: 1.77-18.5), impaired postprocedural TIMI flow (OR = 11.72; 95%CI: 2.64-52.10), and cardiogenic shock at presentation (OR = 11.02; 95%CI: 2.84-42.80) were independent predictors of mortality. CONCLUSIONS: In STEMI patients undergoing PPCI, SARS-CoV-2 positivity is independently associated with impaired reperfusion and with a higher risk of in-hospital mortality, especially among male patients. Age ≥ 75 years, cardiogenic shock, and impaired postprocedural TIMI flow independently predict mortality in this high-risk population.

[Reverse Takotsubo ou myocardite fulminante ? Succès de VA ECMO chez une patiente ayant une atteinte cardiaque liée COVID 19]. / Reverse TakoTsubo or Fulminant myocarditis ? Life saving VA ECMO in a COVID 19 patient.

A 45 years old female patient was admitted to our facility for COVID -19 infection complicated by fulminant cardiac injury and refractory cardiogemic shock. She had echographic findings of reverse takotsubo cardiomyopathy. She was successfully treated by VA-ECMO allowing complete revocery of the left ventricule function and weaning from support.

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.

Fulminant Myocarditis 24 Days after Coronavirus Disease Messenger Ribonucleic Acid Vaccination.

A 60-year-old Japanese woman was hospitalized for cardiogenic shock 24 days after receiving the second dose of the coronavirus disease 2019 BNT162b2 vaccine. Impella CP left ventricular assist device implantation and venoarterial peripheral extracorporeal membranous oxygenation were immediately initiated along with inotropic support and steroid pulse therapy, as an endomyocardial biopsy specimen showed myocarditis. Three weeks later, her cardiac function had recovered, and she was discharged. An immune response associated with the presence of spike protein in cardiac myocytes may be related to myocarditis in the present case because of positive immunostaining for severe acute respiratory syndrome coronavirus 2 spike protein and C4d in the myocardium.

COVID-19 Myocarditis: An Emerging Clinical Conundrum.

Coronavirus Disease 2019 (COVID-19) has been a significant cause of global mortality and morbidity since it was first reported in December 2019 in Wuhan, China. COVID19 like previous coronaviruses primarily affects the lungs causing pneumonia, interstitial pneumonitis, and severe acute respiratory distress syndrome (ARDS). However, there is increasing evidence linking COVID-19 to cardiovascular complications such as arrhythmias, heart failure, cardiogenic shock, fulminant myocarditis, and cardiac death. Given the novelty of this virus, there is paucity of data on some cardiovascular complications of COVID-19, specifically myocarditis. Myocarditis is an inflammatory disease of the heart muscle with a heterogenous clinical presentation and progression. It is mostly caused by viral infections and is the result of interaction of the virus and the host's immune system. There have been several case reports linking COVID-19 with myocarditis, however the true mechanism of cardiac injury remains under investigation. In this paper we review the clinical presentation, proposed pathophysiology, differential diagnoses and management of myocarditis in COVID-19 patients.

Cardiac involvement in cancer patients under chemotherapy and diagnosed with COVID-19: case report and literature review.

Many cases of severe cardiac complications due to Coronavirus disease 2019 (COVID-19) were reported. Cancer and chemotherapy appear to be risk and prognostic factors for COVID-19. A 49-year-old Female, with a history of breast cancer treated by tumorectomy and anthracycline-based chemotherapy was admitted with acute respiratory distress syndrome (ARDS) confirmed as COVID-19. She also had elevated troponin I level (up to 43 g/L), and diffuse myocardial hypokinesia along with severe left ventricle dysfunction on echocardiography. Initial treatment included hydroxychloroquine, azithromycin, corticosteroids and mechanical ventilation. The evolution was marked by QT interval prolongation (QTc=523 ms) and occurrence of cardiogenic shock. The patient died of hemodynamic instability reluctant to resuscitation measures at the 2ndday of hospitalization. COVID-19 patients may develop severe cardiac complications such as myocarditis and heart failure. Receiving chemotherapy especially anthracyclines may be a precipitating and prognostic factor of cardiac manifestations in COVID-19 cancer patients.

Opposing forces of cardiogenic shock: left ventricular outflow obstruction, severe mitral regurgitation, and left ventricular dysfunction in Takotsubo cardiomyopathy.

Rates of stress (Takotsubo) cardiomyopathy have increased during the coronavirus pandemic due to social stressors, even in patients who are not infected with the virus. At times, Takotsubo cardiomyopathy (TC) may present as cardiogenic shock. Herein, we present a case during the pandemic of shock from TC secondary to left ventricular outflow tract obstruction (LVOTO), mitral regurgitation (MR), and left ventricular (LV) dysfunction. The contrasting management strategy of LVOTO, MR, and LV failure was cause for clinical challenge, and we highlight the balance of treating these opposing forces.

Coronavirus-Associated Coagulopathy After Trauma.

Coronavirus disease 2019 (COVID-19) is linked with a hypercoagulable state called COVID-19-associated coagulopathy (CAC). Due to elevated levels of factor VIII and fibrinogen as well as inflammation-linked hyperviscosity of blood, the risk for venous thromboembolism is increased in patients who have CAC. We report the case of a patient with recent COVID-19 infection and no other past medical history who presented after a motorcycle collision with left middle and distal femur fractures, who underwent retrograde intramedullary nailing, and then developed immediate massive bilateral pulmonary emboli. The patient was treated with tissue plasminogen activator administration via bilateral pulmonary artery thrombolysis catheters without improvement, and was then placed on venoarterial extracorporeal membrane oxygenation for subsequent cardiogenic shock. During a 58-day hospital stay, the patient recovered and was discharged with a good long-term prognosis. In this report, we discuss CAC, the role of surgical critical care in the management of the disease, and issues specific to this patient's disease process and treatment.

Multisystem inflammatory syndrome in adults (MIS-A) following COVID-19 requiring venoarterial extracorporeal membrane oxygenation.

The SARS-CoV-2 virus has caused a global pandemic with serious impact around the world. Patients most commonly present with severe lung involvement and acute respiratory failure; however, multisystem inflammatory syndrome in adults (MIS-A) is a known-although rare-complication. We present a case of a 49-year-old patient who presented with combined cardiogenic and vasodilatory shock and was diagnosed with MIS-A. He initially required venoarterial extracorporeal membrane oxygenation and Impella for haemodynamic support but was able to be weaned off these devices with complete recovery of left ventricular systolic function. This case demonstrates that MIS-A may present as haemodynamic collapse in adults, but complete recovery is possible with proper haemodynamic support.

A case of fulminant myocarditis due to COVID-19 in an adolescent patient successfully treated with venous arterial ECMO as a bridge to recovery.

Emerging data suggest an association between severe acute respiratory syndrome coronavirus 2 and the development of acute myocarditis, with children and older adults being most at risk. We describe the clinical course of a previously healthy 12-year-old female who rapidly deteriorated into cardiogenic shock and arrest due to coronavirus disease 2019 induced fulminant myocarditis, necessitating venous-arterial extracorporeal membrane oxygenation as a bridge to full recovery. This case highlights the importance of early clinical recognition of myocardial involvement, and the benefits of taking a multidisciplinary approach in treating these patients.

[Acute myocardial infarction and cardiogenic shock in patient with COVID-19].

The conditions of the pandemic caused by the novel coronavirus infection (COVID-19) are associated with overloading intensive care units, conversion of hospitals, and changes in routing of patients with acute cardiovascular pathology. At the same time, medical practice is still challenged to provide medical care to patients with acute coronary syndrome (ACS). Patients with COVID-19 and acute myocardial infarction (AMI) are at a higher risk of death while the incidence of this combination of diseases will be growing. This article describes a case of diagnosis and treatment of COVID-19 in a 69-year-old patient who was urgently hospitalized with cardiogenic shock associated with ACS, electrocardiographic signs of complete left bundle branch block, and left ventricular ejection fraction of 19 %. Coronary angiography with stenting was successfully performed in the conditions of extracorporeal membrane oxygenation. The patient received long-term intensive therapy in the intensive care unit followed by symptomatic treatment in the cardiac surgery unit. The patient's condition gradually improved and he was discharged from the hospital on the 56th day. The strategy of intensive care and active follow-up helped saving life of the patient with COVID-19 and AMI.

Multimodality imaging and histopathology in a young man presenting with fulminant lymphocytic myocarditis and cardiogenic shock after mRNA-1273 vaccination.

A 38-year-old man presented with several days of chest pain and shortness of breath 8 days after receiving the first dose of an mRNA-1273 vaccine. The patient was found to have new left ventricular ejection fraction of 10% in the setting of hypotension and cardiogenic shock requiring mechanical support with an axial flow catheter pump. The presentation was concerning for acute fulminant myocarditis secondary to an inflammatory response from the recent mRNA-1273 vaccine. The patient was treated with pulse dose steroids for 3 days, ultimately leading to haemodynamic recovery and removal of mechanical circulatory support. Endomyocardial biopsy was performed and showed focal lymphocytic interstitial infiltrate with myocyte damage consistent with lymphocytic myocarditis. The patient had improvement of cardiac function which was seen on serial imaging.

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.