COVID-19 Associated Fulminant Myocarditis: A Multidisciplinary Approach to Treatment Utilizing Advanced Mechanical Circulatory Support and Anti-Viral Medical Therapies

Abstract

A 58-year-old man presented with fever, chills, nausea, vomiting, and diarrhea. A presumptive diagnosis of viral gastroenteritis was made and fluid resuscitation was undertaken. An initial nasopharyngeal COVID-19 swab was negative. CT scan of the chest and abdomen showed no acute pathology. The EKG, however, showed ST-segment elevation anterolaterally and an echocardiogram demonstrated severe LV dysfunction. His condition deteriorated requiring intubation. Cardiac catheterization showed normal coronary arteries and elevated right-sided filling pressures. Biventricular VADS were placed percutaneously (BiPella®). His condition failed to improve and support was escalated to VA-ECMO. The patient was transferred to a quaternary care center whereupon a repeat COVID-19 test was positive. Inflammatory biomarkers were markedly elevated. The diagnosis of COVID-19 associated fulminant myocarditis was made. The patient received IV steroids, broad-spectrum antibiotics, and enrolled in a Phase 1 convalescent plasma trial. In addition, CRRT was initiated for renal failure. His condition rapidly improved and mechanical circulatory support was discontinued. He was discharged and maintained on hemodialysis until his kidney function normalized several months later. His Ejection Fraction at the time of discharge was 65%.

Clinical and Histopathologic Features of Myocarditis in Multisystem Inflammatory Syndrome (Adult)–Associated COVID-19

“…The early implantation of MCS in the form of VA-ECMO or a percutaneous BiVAD restored vital organ perfusion and allowed time for investigation and initiation of definitive management. There were limited reports describing the use of MCS devices for fulminant myocarditis in MIS-A associated with SARS-CoV-2 (5, 12, 13). To our knowledge, there were only three cases of MIS-A associated with SARS-CoV-2 with fulminant myocarditis that required ECMO and four cases that required intra-aortic balloon pump (5, 12–14).…”

“…There were limited reports describing the use of MCS devices for fulminant myocarditis in MIS-A associated with SARS-CoV-2 (5, 12, 13). To our knowledge, there were only three cases of MIS-A associated with SARS-CoV-2 with fulminant myocarditis that required ECMO and four cases that required intra-aortic balloon pump (5, 12–14). The reported duration of MCS ranged between 5 and 50 days, whereas in this case series, the duration was between 3 and 8 days.…”

COVID-related Constrictive Pericarditis Requiring Pericardiectomy: A Case Report

“…4 Samuels and colleagues managed a 58-year-old man with COVID-19 who presented with cardiogenic shock with a percutaneous ventricular assistive device (VAD) followed by extracorporeal membrane oxygenation (ECMO). 5 These case reports added to the spectrum of cardiac disease processes associated with COVID-19 and the treatments necessary to manage them in the acute phase. The consequences of the infection beyond the initial weeks and months of disease onset was unknown at the time.…”

COVID-Related Constrictive Pericarditis Requiring Pericardiectomy: A Case Report

“…For example, Walker and others treated a COVID-19 infected 30-year-old with pericardial tamponade utilizing a surgical subxiphoid pericardial window [4]. Samuels and colleagues managed a 58-year-old man with COVID-19 who presented in cardiogenic shock with a percutaneous ventricular assist device (VAD) followed by extracorporeal membrane oxygenation (ECMO) [5]. These case reports added to the spectrum of the cardiac disease processes associated with COVID-19 and the treatments necessary to manage them in their acute phase.…”