key: cord-1008305-rro8lyuz authors: Xanthopoulos, Andrew; Triposkiadis, Filippos; Starling, Randall C title: “Care for patients with ventricular assist devices and suspected COVID‐19 infection” date: 2020-05-21 journal: Eur J Heart Fail DOI: 10.1002/ejhf.1907 sha: abb368831c711cec41ed1776e05ff9b65595a033 doc_id: 1008305 cord_uid: rro8lyuz nan be more pertinent in grading COVID-19 severity in LVAD patients (3) . However, the increase in LDH in LVAD patients may raise specific concerns since it is also a marker of hemolysis and a harbinger of LVAD thrombosis and concomitant stroke (7) . Infection, itself, acts as a trigger for inflammatory response predisposing to pump thrombosis, ischemic or hemorrhagic stroke in LVAD patients (8). Of concern, abnormal coagulation parameters have been reported in hospitalized patients with severe COVID-19 (D-dimer, fibrin degradation product levels, prothrombin time and activated partial thromboplastin time) (9) . The differential diagnosis between worsening HF and/or LVAD thrombosis may be challenging when dyspnea and fatigue are reported in the COVID-19 infected LVAD patient along with the aforementioned laboratory abnormalities. Timely and accurate COVID-19 laboratory testing is an essential part of the management of COVID-19. Given the presence of a number of circulating respiratory viruses, differentiating COVID-19 from other pathogens (e.g. influenza), is important and done using upper or lower respiratory tract samples for reverse transcriptasepolymerase chain reaction and bacterial cultures. Ground-glass opacities on computed tomography are suggestive but not specific. Low risk LVAD patients with COVID-19 can be treated at home, whereas those at high risk should be hospitalized, ideally at an experienced LVAD center (Figure 1) . Home management requires that healthcare professionals innovate ways to follow LVAD patients virtually and advise them with instructions to self-quarantine ("stay at home"), take hygiene actions and social distancing measures for prevention of disease and transmission, since prevention is currently the best strategy for COVID-19. Healthcare professionals should limit all elective medical visits and testing, arrange for in home blood draws and home international normalized ratio (INR) monitoring as well as emphasize the importance of nutrition, sleep and exercise for immune system health. Regarding medical treatment, many LVAD patients are treated with renin-angiotensin-aldosterone (RAAS) inhibitors, which may increase the expression of ACE2, and this has raised concerns regarding their safety. However, RAAS inhibitors are indispensable for HF management, and the scientific societies strongly recommended to physicians and patients not to discontinue treatment. Finally, the patients' families and caregivers must also be protected and practice selfcare measures for safety. Unfortunately, providers currently rely upon face to face visits to follow LVAD patients and there is limited embedded technology within current LVADs to provide remote monitoring capabilities. Most LVAD centres have adapted their face to face contacts to virtual or telephone contacts. Assessment provided with a virtual visit can include evaluation of LVAD patient's clinical status and screening for adverse events, medication review and management, review of LVAD controller parameters, as well as counseling (10) . Hospital management requires that health care organizations prepare to address the high demand for care of increased numbers of patients with moderate or severe respiratory illnesses, focusing on the availability of ventilation equipment. Patients with acute hypoxemic respiratory failure due to COVID-19 may have a poor tolerance to high positive end-expiratory pressure (PEEP), resulting from lung damage (11) . Although prone ventilation may be effective in COVID-19 related severe ARDS (improves lung mechanics and gas exchange), it may be problematic in This article is protected by copyright. All rights reserved. HF patients on LVAD support as prone positioning could result in complications such as compression of outflow graft and driveline, impaired venous return from increased thoracic pressure, hardware malpositioning, and worsening RV hemodynamics. A case report of an LVAD patient undergoing spine surgery documents the rapid physiologic changes with prone positioning and the need for an experienced clinician to make rapid clinical management decisions (12) . However, the probability of impaired functioning of the LVAD by rotation or mechanical compression seems to be very low and overcome with proper positioning and use of pillows. A severe complication commonly encountered in ARDS is right ventricular (RV) failure, which is associated with high mortality rate despite best standards of care (13) . RV failure in this setting is due to a combination of factors including depressed RV contractility, elevated pulmonary vascular tone, hypercapnia, sepsis, and positive pressure ventilation. Standard hemodynamic monitoring including right heart catheterization can provide evidence indicative of acute RV dysfunction. Point of care bedside echo may be informative and provide an assessment of RV structure and function (RV dilation, hypocontractility, and septal shifting toward the LV). Nevertheless, echocardiography and right heart catheterization should be deferred in mild cases or when the information derived from those tests is expected to have no impact on clinical decision making, in order to limit healthcare professionals' exposure to COVID-19 (3). Although LVAD is an effective treatment for cardiogenic shock, it cannot protect for hypotension and vasoplegia with cytokine storm due to COVID-19 and This article is protected by copyright. All rights reserved. Accepted Article complicating infections. Septic shock and acute kidney injury may occur in a significant proportion of patients with COVID-19-related critical illness and are associated with increasing mortality. There is no definitive therapy for COVID-19. Hydroxychloroquine is frequently chosen as initial treatment, as it presumably reduces in vitro SAR-CoV-2 cell entry COVID-19 and preliminary data are encouraging (3, 17) . Timely control of the cytokine storm in its early stage with immunomodulators, cytokine antagonists (toclizumab), and reduction of lung inflammatory cell infiltration may be beneficial in COVID-19. Remdesivir appears to be effective and may become the standard of care (18) . A small percentage (1-3%) of LVAD patients with COVID-19 will require ECMO support which is feasible only in very specialized centers. Finally, it is important to caution that new data emerge daily regarding clinical characteristics, treatment options, and outcomes for COVID-19 and that currently optimized supportive care remains the mainstay of therapy. Accepted Article hospitalization should be transported to centers experienced in the care of LVAD patients which must prepare infrastructure and algorithms to care and innovate strategies for this unique patient population. A.X. has received honoraria from Novartis Left ventricular assist device therapy in advanced heart failure: patient selection and outcomes Coronavirus Disease 2019 (COVID-19) and Cardiovascular Disease. Circulation The Imperfect Cytokine Storm: Severe COVID-19 with ARDS in Patient on Durable LVAD Support. JACC Case Rep The impact of hypogammaglobulinemia on infection outcome in patients undergoing ventricular assist device implantation Effects of left ventricular assist device support on biomarkers of cardiovascular stress, fibrosis, fluid homeostasis, inflammation, and renal injury Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Unexpected abrupt increase in left ventricular assist device thrombosis What Causes LVAD-Associated Ischemic Stroke? Surgery, Pump Thrombosis, Antithrombotics, and Infection Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia Virtual Visits for Care of Patients with Heart Failure in the Era of COVID-19: A Statement from the Heart Failure Society of America Intubation and Ventilation amid the COVID-19 Outbreak: Wuhan's Experience Anesthetic Challenges for Posterior Spine Surgery in a Patient With Left Ventricular Assist Device: A Case Report. A Case Rep The Right Ventricle in ARDS Right Heart Failure After Left Ventricular Assist Device Placement: Medical and Surgical Management Considerations International Society for H, Lung T. The 2013 International Society for Heart and Lung Transplantation Guidelines for mechanical circulatory support: executive summary Right ventricular afterload sensitivity dramatically increases after left ventricular assist device implantation: A multi-center hemodynamic analysis Cytokine Storm in COVID-19 and Treatment Apr 10 Compassionate Use of Remdesivir for Patients with Severe Covid-19 This article is protected by copyright. All rights reserved. Funding: None