Table 1.
Clinical, analytical, and imaging features, treatment, and outcome of 4 patients with cardiogenic shock complications
| Case 1 | Case 2 | Case 3 | Case 4 | |
|---|---|---|---|---|
| Sex | Woman | Man | Man | Woman |
| Age, y | 42 | 50 | 75 | 37 |
| Weight, kg/BMI | 50/19.5 | 66/21.7 | 65/22.9 | 120/43 |
| CVRF | Dyslipidemia | None | None | Morbid obesity |
| Chronic treatment | Drospirenone-ethinyl estradiol 3/0.02 mg (oral contraceptive) | None | None | None |
| Comorbidities | None | Copper metabolism disorder of unknown origin Benign right mediastinal tumor |
None | History of DVT 8 years previously due to immobilization after a fracture |
| Symptom onset to emergency room admission, d | 12 | 8 | 2 | 10 |
| Symptoms | Dyspnea, diarrhea, vomiting, anosmia, and dysgeusia | Fever, dyspnea, and cough | Dyspnea | Fever, dyspnea and chest pain |
| ECG | Sinus rhythm with recent-onset LBBB | Sinus tachycardia with lateral ST segment elevation, 2 mm | Complete atrioventricular block with inferior ST segment elevation | Sinus tachycardia SI QIII TIII pattern Inconclusive anterior ST segment elevation |
| Chest radiography | Cardiomegaly. Diffuse bilateral infiltrates | Extensive bilateral lung involvement: faint patchy opacities in the right lung and faint, diffusely increased density of the left lung, predominantly in the middle fields No cardiomegaly | Bilateral parenchymal opacities No cardiomegaly |
Increased peripheral density in the right lung base obliterating the costophrenic angle, consistent with peripheral lung consolidation |
| Echocardiography | LV dilation with severely reduced LVEF and global hypokinesis No pericardial effusion |
No LV dilation, akinesis of all basal segments and hypercontractility of mid-apical segments Normal right chambers No pericardial effusion |
No LV dilation, inferior basal akinesis with moderate dysfunction Severe RV dilation with severe dysfunction No pericardial effusion |
Not done |
| Catheterization | Coronary arteries normal Pulmonary arteries normal |
Coronary arteries normal Ventriculography shows an inverted takotsubo pattern |
Thrombotic occlusion of middle segment of the right coronary artery | No time to perform catheterization |
| Troponin I, ng/mL | 70.4 (NV < 0.1) | 64.1 | 500 | 0.4 |
| BNP, pg/mL | Not available | 790.7 | 2212.4 | 382 |
| IL-6, pg/mL | Not available | 260.2 | Not available | 50.93 |
| D dimer, ng/mL | 4342 (NV < 500) | 2442 | 7530 | 3128 |
| CRP, mg/L | 1 | 379.5 | 113.8 | 82.9 |
| Lymphocytes, 103/L | 8.04 | 0.80 | 0.90 | 1.91 |
| Hemoglobin, g/dL | 8 | 15.6 | 21.2 | 13.7 |
| Ferritin, ng/mL | Not available | 986.67 (NV 20-300) | Not available | 232 |
| Presumptive cardiologic diagnosis | Fulminant myocarditis | Stress cardiomyopathy Inverted takotsubo |
Inferior infarction, Killip III | High-risk bilateral PTE |
| Treatment for COVID-19 | No time to establish treatment | Hydroxychloroquine 200 mg/12 h Lopinavir-ritonavir 200/50 mg, 2 tablets/12 h Tocilizumab 400 mg/day Azithromycin 500 mg/day Methylprednisolone 30 mg/day (tapering dose) |
Since positive test results for COVID-19, no time to establish treatment | Since positive test results for COVID-19, no time to establish treatment |
| Anticoagulant /antiplatelet therapy | NFH | No | Aspirin 300 mg and ticagrelor 180 mg* Tirofiban i.v. |
Enoxaparin 120 mg/12 h Fibrinolysis with i.v. tPA |
| Clinical course | Cardiorespiratory arrest CPR maneuvers Arrhythmic storm Refractory VF Cardiogenic shock VA-ECMO and IABC Mechanical ventilation Death |
Mixed shock (initially cardiogenic and later septic) Mechanical ventilation Vasoactive support (3 days) Discharged home at 11 days Normalization of contractility changes |
Cardiorespiratory arrest Primary VF Primary PCI Cardiogenic shock refractory to vasoactive amines Mechanical ventilation Multiorgan failure Death |
Cardiogenic shock Cardiorespiratory arrest and electromechanical disassociation Died following CPR maneuvers |
BNP, brain natriuretic peptide; CPR, cardiopulmonary resuscitation; CRP, C-reactive protein; CVRF, cardiovascular risk factors; DVT, deep vein thrombosis; IABC, intra-aortic balloon counterpulsation; i.v., intravenous; LBBB, left bundle branch block; LV, left ventricle; LVEF, left ventricular ejection fraction; NFH, non-fractionated heparin; NV, normal values; PCI, percutaneous coronary intervention; PTE, pulmonary thromboembolism; RV, right ventricle; tPA, tissue plasminogen activator; VA-ECMO, venoarterial extracorporeal membrane oxygenation; VF, ventricular fibrillation;
*
Ticagrelor was administered despite knowledge of potential interactions with lopinavir-ritonavir. COID-19 was diagnosed after the primary PCI.