NOSOCOMIAL COVID-19 INFECTION IN AN LVAD PATIENT

Background

COVID-19 infection in an LVAD patients presents a unique challenge due to the patient’s altered immunity. We describe a case of nosocomial COVID-19 infection in an LVAD patient and its management.

Case

78 year old male with HFrEF with HeartMate II LVAD was admitted for evaluation of elevated LDH of 878 u/L and an undetectable haptoglobin. Patient received tPA for pump thrombosis and later underwent pump exchange via the subcostal approach. One week post surgery he developed a fever of 101.6 F. Blood Cultures yielded no growth, urine analysis was unremarkable. Chest x-ray showed right lobe opacity. A COVID-19 nasopharyngeal swab done was positive. At the time of diagnosis of viral pneumonia, white blood cell count was 3.13 K/uL, ferritin was 1655 ng/mL and procalcitonin was 0.13 ng/mL. Patient required 2 liters supplemental oxygen. Infectious disease team was consulted for management of COVID -19 Pneumonia, and the patient was started on dexamethasone for 10 days, and remdesivir for 5 days. Patient made a complete recovery and was discharged home. At the time of discharge his ferritin was 703 ng/mL and LDH was 255 u/L.

Decision-making

Patients with LVAD have an altered immunological response, with loss of Th1 cytokine producing CD4 T-cells and increased apoptosis of CD4 and CD8 T cells leading to defects in cellular immunity and an increased severity of infections. In addition, thrombosis is a common challenge faced in LVAD patients that can be exacerbated by COVID-19. Data is scant regarding the outcome of LVAD patients with COVID-19. Timely use of dexamethasone and remdesivir, and ensuring appropriate anticoagulation is the basis of management of mild-to-moderate COVID-19 infection. The unpredictability of COVID-19 infection in this functionally immuno-compromised population requires stringent precautionary measures to prevent undue exposure of LVAD patients from asymptomatic carriers.

Conclusion

Adherence to infection control practices, limiting visitors and using electronic means of communication with families can prevent nosocomial COVID-19 infection in hospitalized LVAD patients. Timely diagnosis and involvement of infectious disease team may prevent a fulminant course.