To the Editor
A 22-year-old postpartum woman was admitted to our tertiary care center with acute respiratory distress syndrome (ARDS) secondary to COVID-19 infection (Figure 1 A). She remained severely hypoxemic on mechanical ventilation despite prone positioning and steroid therapy. Our multidisciplinary committee decided to trial mechanical cardio-respiratory support, utilizing a TandemLife Protek DuoTM (TPD; TandemLife, Pittsburgh, PA) right ventricular assist device with oxygenator (Oxy-RVAD). It resulted in a short-term improvement in hypoxemia. However, shortly after return to the intensive care unit, the patient suffered a cardiac arrest; a bedside transthoracic echocardiogram (TTE) showed severely reduced right- (RV) and left ventricle (LV) function. She was emergently cannulated for veno-arterial extracorporeal membrane oxygenation (VA-ECMO). An ImpellaTM (Abiomed, Danvers, MA) LV assist device was also placed to unload the ‘trapped’ LV (Figure 1B). A repeat TTE revealed improved LV function and an ejection fraction (EF) of 45% on hospital day 14. She was downgraded form VA-ECMO and Impella support to Oxy-RVAD. On hospital day 40, another TTE noted complete LV and RV function recovery, and the patient was transitioned to standard veno-venous (VV)- ECMO for mobility and strength recovery.
FIG 1.
Rapidly enlarging pulmonary artery aneurysm and closure in a COVID-19 patient on cardio-respiratory support. (A) CT chest with COVID-19 ARDS, (B) Oxy-RVAD cannula in the main pulmonary artery and Impella LVAD in the left ventricle, (C and D) 3-dimensional reconstructed images showing the PA aneurysm, (E) CT slice showing PA aneurysm, (F) Angiogram with PA aneurysm pre-, (G) post-closure, (H) 3-dimensional reconstructed image showing minimal filling of closed PA aneurysm. CT, Computed Tomography; COVID-19, Coronavirus disease 2019; RVAD, Right Ventricular Assist Device; LVAD, Left Ventricular Assist Device; PA, Pulmonary Artery; LV, Left Ventricle.
ECMO was capped on hospital day 117 for 36 hours and liberated on hospital day 121. On hospital day 140, a follow-up computed tomography (CT) chest to assess pulmonary injury incidentally noted a large main pulmonary artery (PA) aneurysm (maximum diameter of 3.5 cm) which continued to enlarge on a repeat CT 48 hours later (Figure 1C, 1D and 1E).
Percutaneous closure of the PA aneurysm was pursued due to concerns of imminent rupture. CT-guided precise location and dimension of the PA aneurysm were assessed, and the patient underwent an uneventful closure with a 12 mm Amplatzer muscular ventricular septal defect closure device (AGA Medical Corp.) (Figure 1F). Follow up angiography revealed exclusion of the pseudoaneurysm (Figure 1G) which was confirmed with a repeat CT scan 1 week later (Figure 1H). Currently the patient is awaiting lung transplantation.
We describe the development of pulmonary artery injury and resultant aneurysm secondary to prolonged Oxy-RVAD support in a patient with COVID-19. Mechanical cardio-respiratory support utilization has increased substantially during the COVID-19 pandemic.1 Vascular complications are common, and the major cause of mortality, in ECMO patients. Health-care providers should be aware of this rare but important complication due to prolonged Oxy-RVAD support.
Footnotes
Authors have no conflict of interest. (1) That the corresponding author has the approval of all other listed authors for the submission and publication of all versions of the manuscript, that all authors have made a significant independent contribution and that no one who justifies being an author has been omitted from authorship. (2) That the work has not been published nor is under consideration for publication elsewhere other than in oral, poster or abstract format, and that appropriate attribution and citation is given for any material reproduced from any other source including the authors' prior publications. (3) That the material in the manuscript has been acquired according to modern ethical standards. (4) That all material conflicts of interest have been declared including the use of paid medical writers and their funding source. (5) That the manuscript will be maintained on the servers of the journals and held to be a valid publication by the journals only as long as all statements in these principles remain true, and that the authors have a duty to notify the journal editors immediately if any of the statements above ceases to be true withdrawn.
Reference
- 1.Shekar K, Badulak J, Peek G, et al. Extracorporeal life support organization coronavirus disease 2019 interim guidelines: A consensus document from an international group of interdisciplinary extracorporeal membrane oxygenation providers. ASAIO J. 2020;66:707–721. doi: 10.1097/MAT.0000000000001193. PMID: 32604322; PMCID: PMC7228451 ELSO Guideline Working Group. [DOI] [PMC free article] [PubMed] [Google Scholar]