First successful treatment of COVID-19 induced refractory cardiogenic plus vasoplegic shock by combination of pVAD and ECMO: A case report

Xavier Bemtgen, Kirsten Krüger, David Alexander Supady, ASAIO Journal Publish Ahead of Print
DOI: 10.1097/MAT.0000000000001178

Case History:

The authors present a 52 y.o. COVID – 19, male patient with a known dilated cardiomyopathy, systolic heart failure and a recent admission for worsening heart failure complicated by a myocardial infarction. The current admission was prompted by cough and shortness of breath. The patient rapidly deteriorated secondary to development of Adult Respiratory Distress Syndrome (ARDS) requiring mechanical ventilation. His course was further complicated by combined cardiogenic and vasoplegic shock (C.I. = 1.8L/min/m2) unresponsive to high doses of vasopressors. On day 3, because of inability to control the shock plus the development of renal failure, a pVAD (Impella CP Smart Assist) was implanted in the cath lab providing 3.5l/min of flow. Lactate normalized and left ventricular end diastolic dimension (LVEDD) diminished. However, the vasoplegic shock persisted requiring continued high dose vasopressors. A V-A ECMO was added day 4 providing 4.5L/min flow. By Day 7 the vasopressors could be withdrawn and the ECMO was changed to a V-V configuration with continued hemodynamic support provided by the Impella. The Impella was successfully weaned at day 19, but V-V ECMO support persists at day 24 suggesting ARDS may be the most resistant of the COVID – 19 complications in this patient.

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Key Points:

  • First case report of pVAD (Impella) combined with ECMO for treatment of refractory cardiogenic and vasoplegic shock in a COVID – 19 patients presenting with ARDS.
  • This case supports the experience that patients of all ages are potentially at risk for severe COVID Complications which are further exacerbated by pre-existing cardiac complications as this patient has coronary artery disease, prior myocardial infarction and a dilated cardiomyopathy with heart failure.
  • Severe shock, cardiac and vasoplegic occur in ARDS patients.
  • Impella CP support rapidly normalized lactate levels and reduced LVEDD, consistent with Left Ventricular unloading.
  • Combined ECMO flow supported oxygenation and provided support to overcome the severe vasoplegic shock, but primarily supported long-term oxygenation.
  • Impella provided the necessary hemodynamic support for cardiogenic shock as measured by lactate reduction with associated favorable left ventricular unloading.