key: cord-323439-z6rghua1
authors: Sampaio, Pedro Paulo N.; Ferreira, Roberto M.; de Albuquerque, Felipe N.; Colafranceschi, Alexandre S.; de Almeida, Alexandre C.P.; Nunes, Marcos Alexandre V.; Filho, João Mansur; Lima, Ricardo Antônio C.
title: Rescue Venoarterial Extracorporeal Membrane Oxygenation After Cardiac Arrest in COVID-19 Myopericarditis: A Case Report
date: 2020-09-30
journal: Cardiovasc Revasc Med
DOI: 10.1016/j.carrev.2020.09.038
sha: 
doc_id: 323439
cord_uid: z6rghua1

Coronavirus Disease-2019 (COVID-19) has been associated with potentially life threatening cardiovascular complications, including fulminant myocarditis and cardiac tamponade. Optimal management strategies are still unclear, including the role of immunomodulatory therapies and extracorporeal membrane oxygenation (ECMO) in the context of cardiogenic shock. We report a case of a middle-aged female with COVID-19 who developed respiratory distress and hemodynamic deterioration with elevated troponin levels on the seventh day of symptoms. Echocardiography demonstrated pericardial effusion with diastolic restriction of the right ventricle. Cardiac arrest developed during pericardiocentesis, resulting in emergency thoracotomy and pericardial drainage. Venoarterial ECMO was subsequently initiated due to refractory cardiogenic shock. Tocilizumab, immunoglobulin, methylprednisolone and convalescent plasma were added to supportive care, with progressive recovery of cardiac function and successful weaning from mechanical ventilation. This case highlights the potential role of ECMO, convalescent plasma and immunomodulatory therapies in the management of cardiogenic shock associated with COVID-19 myopericarditis.

Coronavirus Disease-2019 (COVID-19) has specific clinical characteristics which differentiate the condition from other respiratory viruses, especially regarding cardiovascular and thrombotic complications. Cardiac injury can occur in up to 28% of hospitalized patients and is associated with worse outcomes [1] . The role of extracorporeal membrane oxygenation (ECMO) in this scenario has yet to be clearly determined, since it has not been available in most healthcare facilities treating patients with COVID-19 around the World. Even in larger case series of hospitalized patients ECMO was rarely used, especially venoarterial [2] . We report a case of COVID-19 myopericarditis complicated by tamponade and cardiac arrest, successfully managed with venoarterial ECMO, convalescent plasma and immunomodulatory therapies.

A 45-year-old female with COVID-19, confirmed 3 days previously by nasopharyngeal swab testing, presented to the emergency department on May 10 th , 2020 following a 7 day progression of dyspnea, fever, myalgia and postural hypotension. The patient had no previous comorbidities and denied any regular medications. On admission, heart rate was 125 bpm, blood pressure 105/72 mmHg, respiratory rate 26 breaths/min and oxygen saturation 100% on room air. Thoracic computed tomography confirmed bilateral pulmonary infiltrates compromising less than 25% of both lungs, in addition to pleural and pericardial effusions ( Fig. 1A and 1B) . Transthoracic echocardiography (TTE) demonstrated normal biventricular function, with moderate pericardial effusion and diastolic restriction of the right ventricle ( Fig. 1C and 1D ). Initial troponin I was 867 pg/mL (reference <34 pg/mL), and the remaining blood tests are shown in Table 1 . Azithromycin, piperacillin/tazobactam and teicoplanin were initiated before admission to the intensive care unit (ICU).

J o u r n a l P r e -p r o o f Journal Pre-proof Within 2 hours of ICU admission, cardiac tamponade developed, necessitating urgent TTE-guided subxiphoid pericardiocentesis. The procedure was unsuccessful and 2 minutes after needle insertion, cardiac arrest in asystole was diagnosed. Emergency thoracotomy was performed and followed by internal cardiac compression and pericardial drainage. The pericardial fluid was citrine yellow and no evidence of ventricular laceration was identified.

Although spontaneous circulation was restored after five minutes, the patient progressed to refractory circulatory shock, despite the administration of noradrenaline, dobutamine, milrinone and vasopressin. New biventricular dysfunction was visualized on TTE and peak troponin levels reached 14,000 pg/mL. Haemodialysis was interrupted on July 2 nd and besides the development of critical illness myopathy, no further complications were identified. Discharge from the ICU occurred on July 4 th , and was followed by further echocardiographic confirmation of complete biventricular recovery. Hospital discharge was given on July 15 th with continuation of physiotherapy and voriconazole for 4 weeks.

Heart failure has been diagnosed in up to 23% of patients with COVID-19, notably as a result of myocarditis, though pericardial involvement and tamponade have also been described [3, 4] . While pericardiocentesis may be life-saving, subsequent management of respiratory insufficiency, myocardial dysfunction and circulatory shock can be challenging, since hemodynamic collapse is usually multifactorial [3] . Although circulatory support should be individualized, venoarterial ECMO may be a suitable choice when simultaneous respiratory and myocardial dysfunction are present. managed with ECMO, only 2 were treated with venoarterial support [5] . As new knowledge continues to evolve in this area, case reports are relevant to provide the foundation for the development of additional research.

Few cases of fulminant myocarditis have been published in this context, and the benefit of ECMO remains uncertain, especially after recovery from cardiac arrest. Only 2 successfully treated cases of COVID-19 fulminant myocarditis and cardiogenic shock have been previously described, of which 1 was treated with venoarterial ECMO. Neither utilized tocilizumab or convalescent plasma as a management strategy. In addition, only 1 report of emergency ECMO cannulation after cardiac arrest in a patient with COVID-19 has been formerly documented, despite a subsequent unfavourable outcome [6] .

In selected cases, ECMO may offer a possibility for spontaneous recovery and administration of immunomodulatory and supportive therapies, though the inherent risks associated with the procedure should be appreciated. Although patients seem to fare poorly in this scenario, our case is distinctive from previous descriptions because of the successful outcome. Selecting the appropriate moment to initiate ECMO is essential to ensure that the management strategy does not inflict a higher risk than the underlying disease. The identification of significant determinants of poor outcomes associated with ECMO support, such as older age, multiorgan failure, systemic comorbidities or severe respiratory compromise, is crucial to aid in clinical decision making in this setting [6] . In our case, though the post cardiac arrest neurological status was still uncertain, the absence of additional predictors of mortality and the early indication of hemodynamic support provided a favourable scenario for recovery of myocardial function.

Optimal management of anticoagulation during ECMO support in COVID-19 is unknown, particularly due to the increased thrombotic risk associated with the disease.

Despite preliminary observational data suggesting higher prophylactic heparin doses in patients with COVID-19, it is unclear whether increasing UFH anticoagulation levels is associated with improved outcomes during ECMO support. Acquired antithrombin deficiency in this scenario can result in both thrombotic and haemorrhagic complications, which results in unpredictable net clinical effects associated with higher anticoagulation doses [2] .

Harlequin syndrome could also be a concern, since pulmonary function in patients with COVID-19 may only recover over several weeks. Switching to venovenous ECMO or optimizing ventilator parameters before removing circulatory support are potential options.

Furthermore, management of bleeding, secondary infections, renal failure and neurological complications are crucial components to achieve a successful outcome.

We describe the first case of fulminant COVID-19 myopericarditis and tamponade successfully treated with venoarterial ECMO, neutralizing antibodies and anti-inflammatory therapies, after recovery from cardiac arrest. Although stunned myocardium might have contributed to the cardiogenic shock, this complication tends to occur after longer periods of cardiac arrest and the subsequent recovery of ventricular function is often sooner than what was observed (<72 hours) [7] . Supportive measures are still essential in this scenario, since evidence-based interventions are currently lacking. subcutaneously. After adjustment for a series of clinical variables, tocilizumab was associated with a significantly reduced risk of mechanical ventilation or death (adjusted hazard ratio 0.61, 95% CI 0.40-0.92; p=0.020), although with a higher incidence of new infections (13% vs 4%, p<0.001) [11] . Though tocilizumab has also been previously used without concomitant plasma therapy or ECMO in a recovered case of COVID-19 myocarditis, randomized trials are still necessary to clarify the exact role of interleukin-6 inhibitors in this context [12] . As such, it is difficult to estimate the influence of these interventions on our patient's outcome until additional research has been published.

Our report illustrates the importance of appropriate supportive measures in fulminant COVID-19 myopericarditis, particularly the potential role of timely venoarterial ECMO support for circulatory shock following recovery from cardiac arrest. Clinical risk stratification should be thoroughly performed in these cases to identify patients who may not benefit from the intervention. Further studies should also explore the effects of convalescent J o u r n a l P r e -p r o o f Figure 1 

Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus infected pneumonia in Wuhan, China

COVID-19 and ECMO: the interplay between coagulation and inflammation-a narrative review

COVID-19 for the Cardiologist

Cardiac Tamponade Secondary to COVID-19

Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome associated with COVID-19: a retrospective cohort study

Cardiovascular collapse in COVID-19 infection: The Role of veno-arterial extracorporeal membrane oxygenation (VA-ECMO)

Reversible myocardial dysfunction in survivors of out-of-hospital cardiac arrest

Effectiveness of convalescent plasma therapy in severe COVID-19 patients

Investigational COVID-19 Convalescent Plasma -Emergency INDs

Tocilizumab for cytokine storm syndrome in COVID-19 pneumonia: an increased risk for candidemia

Tocilizumab in patients with severe COVID-19: a retrospective cohort study

A Recovered Case of COVID-19 Myocarditis and ARDS Treated With Corticosteroids, Tocilizumab, and Experimental AT-001

Diagnostic and therapeutic procedures were supported by the Samaritano Hospital, Botafogo.The authors declare that there is no conflict of interest.J o u r n a l P r e -p r o o f Journal Pre-proof