key: cord-1044959-htq943rv
authors: Flagiello, Michele; Al Harthy, Ahmed; Boccalini, Sara; Jacquemet, Louis; Obadia, Jean F.; Baudry, Guillaume; Pozzi, Matteo
title: Veno‐arterial extracorporeal membrane oxygenation for COVID‐19‐associated acute myocardial injury complicated by refractory cardiogenic shock
date: 2021-08-15
journal: J Card Surg
DOI: 10.1111/jocs.15919
sha: 167d161864e6ad622abc36243afd9c07e09879dd
doc_id: 1044959
cord_uid: htq943rv

Cardiovascular system involvement and its negative prognostic impact have been increasingly identified in coronavirus disease 2019 (COVID‐19) patients. Optimal medical treatment allows for safe management of most of these cardiovascular presentations while COVID‐19‐associated refractory cardiogenic shock could be rescued by veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO). We present a case of acute myocardial injury related to COVID‐19 complicated by refractory cardiogenic shock and treated by VA‐ECMO implantation.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)

is the etiologic agent of the pandemic coronavirus disease 2019 (also known as COVID-19), whose clinical presentation can vary from mild respiratory symptoms to severe multiorgan failure. The respiratory tract is most frequently affected and acute respiratory distress syndrome (ARDS) is the leading cause of mortality. 1 However, cardiovascular system involvement and its negative prognostic impact have been increasingly identified in COVID-19 patients. 2 Myocardial injury in COVID-19 has not been completely understood and seems related to various pathophysiologic mechanisms as cytokine storm, viral myocarditis, and stress cardiomyopathy. 2 Optimal medical treatment, including inotropes and vasopressors, allows for safe management of most of these cardiovascular presentations whereas COVID-19-associated refractory cardiogenic shock could be rescued by veno-arterial extracorporeal membrane oxygenation (VA-ECMO). 3, 4 We present a case of acute myocardial injury related to COVID-19 complicated by refractory cardiogenic shock without ARDS and treated by VA-ECMO implantation.

A previously healthy 30-year-old woman (170 cm, 67 kg, body mass index 23.1 kg/m 2 ) was admitted for fever, chest pain, and worsening dyspnea in the last 5 days. At presentation, her blood pressure was 80/50 mm Hg and oxygen saturation 96% on 3 L of oxygen by nasal cannula. The electrocardiogram showed sinus tachycardia at 110 bpm and a diffuse ST-segment elevation (more marked in the lateral and inferior leads; Figure 1 ). Blood analysis revealed leukocytosis with lymphopenia (white blood cells count 14.9 × 10 9 /L, neutrophils 81.5%, and lymphocytes 10.8%) and increased highsensitivity troponin I (5891 ng/L). Arterial blood gas analysis de- Acute myocardial injury is reported in more than 20% of COVID-19 patients and yields increased mortality. 2 The role of VA-ECMO in the management of patients with COVID-19 acute myocardial injury is still unclear and the existing literature is limited to isolated case reports. [6] [7] [8] Although cardiac injury usually appears within the context of the overall respiratory infection rather than the first manifestation of disease, 6 In the specific setting of COVID-19-associated cardiovascular manifestations, viral myocarditis is a rare cause of acute myocardial injury and the term is used more often on the basis of increased blood troponin levels or signs of myocarditis on cardiac magnetic resonance imaging rather than on a pathological tissue diagnosis. 9 Despite a complex pathophysiology, the high potential of myocardial recovery is a key feature in COVID-19-associated acute myocardial injury and should help defining the role of VA-ECMO in the management of this subgroup of COVID-19 patients.

Acute myocardial injury may negatively affect the clinical course of COVID-19 patients. VA-ECMO support should be considered in rapidly evolving acute myocardial injury with refractory cardiogenic shock despite optimal medical treatment. Further studies are strongly recommended to evaluate the effectiveness and safety of VA-ECMO in the management of COVID-19-associated acute myocardial injury complicated by cardiogenic shock.

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

COVID-19 and cardiovascular disease

Extracorporeal membrane oxygenation for COVID-19: updated 2021 guidelines from the extracorporeal life support organization

The role of extracorporeal membrane oxygenation circulatory support in the 'crash and burn' patient: from implantation to weaning

Outcomes after extracorporeal life support for postcardiotomy cardiogenic shock

Myocardial localization of coronavirus in COVID-19 cardiogenic shock

COVID-19 "Fulminant Myocarditis" successfully treated with temporary mechanical circulatory support

Rescue venoarterial extracorporeal membrane oxygenation after cardiac arrest in COVID-19 myopericarditis: a case report

Pathological evidence for SARS-CoV-2 as a cause of myocarditis: JACC review topic of the week

Veno-arterial extracorporeal membrane oxygenation for COVID-19-associated acute myocardial injury complicated by refractory cardiogenic shock

The authors declare that there are no conflict of interests.

http://orcid.org/0000-0001-8750-9210Matteo Pozzi http://orcid.org/0000-0001-6550-0872