MANAGEMENT OF COVID-19 MYOPERICARDITIS WITH AN IMPELLA CP

Background

Experience with mechanical circulatory support devices for COVID19 cardiomyopathy is limited. We seek to share our management of COVID-19-induced myopericarditis with an Impella CP (Abiomed, Danvers, Massachusetts) device.

Case

A 40-year-old female with hypertension presented with COVID19 pneumonia. TTE showed a newly reduced left ventricular ejection fraction (LVEF) 20-25% and a small pericardial effusion without tamponade. Over 24 hours, the patient, though stable on high flow nasal cannula, required increasing doses of norepinephrine.

Decision-making

The multidisciplinary HEART team discussed mechanical circulatory support for her refractory hemodynamic instability. An optimistic prognosis was suggested by the young age, absence of comorbidities, and Respiratory ECMO Survival Prediction (RESP) score 6 and Survival after Veno-Arterial ECMO (VA-ECMO) (SAVE) score 4. We considered her predominant need for ionotropic rather than respiratory support and selected the Impella device in lieu of VA-ECMO. Furthermore, although left ventricular decompression was possible with ECMO, the Impella device offered a less invasive alternative.

Conclusion

Initial cardiac output and index were 2.32 L/min and 1.33 L/min/m2, respectively, and PAO2 saturation 43%. An Impella device was placed and subsequent pericardial window was performed. Hemodynamics improved to 4.8-5.0 L/min, 2.75-2.87 L/min/m2, and >65%, respectively. Along with supportive care, LVEF improved from 35-40% to 65-70% by hospital day 14. Impella CP was weaned off and patient extubated and conversational 18 days after the procedures. However, two days after extubation, she was re-intubated for acute hypoxic respiratory failure presumably secondary to intrinsic COVID19 lung injury. TTE showed normal LV/RV systolic function and no pericardial effusion. Brain MRI showed anoxic brain injury. Patient expired on hospital day 22. Our case describes the successful stabilization of COVID-19 myopericarditis with a percutaneous left ventricular assist device and pericardial window, though ultimately unsuccessful in fighting the multisystem disease.