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An event is serious (based on the ICH definition) when the patient outcome is:
* death
* life-threatening
* hospitalisation
* disability
* congenital anomaly
* other medically important event
A 54-year-old man experienced lack of efficacy following treatment with norepinephrine for cardiogenic shock.
The man presented to the hospital with 4 weeks of progressive dyspnoea, leg swelling and weight gain. His symptoms began 4 weeks after experiencing influenza-like symptoms after a trip to China during the height of their COVID-19 outbreak. He was admitted to the COVID unit in cardiogenic shock and was later intubated for acute hypoxic respiratory failure. Laboratory investigations revealed acute kidney injury, elevated transaminases, lactic acidosis, elevated pro-BNP N-terminal and elevated troponin. A transthoracic echocardiogram showed severe biventricular failure with a left ventricular ejection fraction of 10% and a left ventricular internal diastolic dimension (LVIDd) of 5.2cm. SARS-CoV-2 RNA was found to be negative twice, but SARS-CoV-2 IgG antibody and SARS-CoV-2 IgA antibody were found to be positive. Urgent right and left heart catheterisation was performed which showed a non-obstructive coronary artery disease and haemodynamics, consistent with cardiogenic shock. He underwent intra-aortic balloon pump (IABP) and received norepinephrine [dosage and route not stated]. However, he showed a fick cardiac output of 3.1 L/min, fick cardiac index of 1.6 L/min/m2, pulmonary capillary wedge pressure of 37mm Hg, right atrial pressure of 25mm Hg and pulmonary arterial pressure of 65/40mm Hg.
In view of the persistent cardiogenic shock on IABP and inotropes, the man was later transitioned to veno-arterial extracorporeal membrane oxygenation and an Impella CP for left ventricular unloading. However, he continued to have persistent INTERMACS I shock and underwent successful implantation of a HeartMate 3 left ventricular assist device with percutaneous temporary right ventricular assist device (RVAD). Pathology of the left ventricular apical core demonstrated polyclonal endocardial infiltration of B-Cells, CD4 and CD8 positive T-Cells, eosinophils, macrophages and plump reactive endothelial cells. He was recovering in the ICU off of vasoactive support with subsequent removal of RVAD.
Reference
- Miller TA, et al. A Case of Suspected Covid 19 Related Cardiomyopathy. Journal of Cardiac Failure 26: S73 abstr. 203, No. 10, Oct 2020. Available from: URL: 10.1016/j.cardfail.2020.09.214 [abstract] [DOI]