Justin Kim, ACNP, MSN (he/him/his)
George Washington University Hospital
Disclosure information not submitted.
David Yamane, BS, MD
Assistant Professor of Emergency Medicine, Anesthesiology, and Critical Care Medicine
George Washington University Hospital, United States
Disclosure information not submitted.
Elizabeth Pocock, MD
Assistant Professor of Cardiac Surgery
George Washington University Hospital, United States
Disclosure information not submitted.
Ramesh Mazhari, MD
Assistant Professor of Cardiology
George Washington University Hospital, United States
Disclosure information not submitted.
Katrina Hawkins, MD
Assistant Professor of Anesthesiology and Critical Care Medicine
George Washington University Hospital, United States
Disclosure information not submitted.
Title: COVID-19 Associated Myocarditis Treated With ECPELLA and Glucocorticoid Therapy: A Case Series
Case Report Body: INTRODUCTION: Two young adults with COVID-19 associated myocarditis and refractory cardiogenic shock, without respiratory failure were successfully treated with venoarterial extracorporeal membrane oxygenation (VA ECMO) and percutaneous left ventricular assist device (pLVAD), or “ECPELLA,” and glucocorticoids.
Description:
Case 1: A previously healthy 23-year-old female presented four days after a COVID-19 diagnosis with fevers, lethargy and hypotension. Labs were notable for Pro-BNP 16,000 pg/mL, lactate 15 mg/dL, troponin 1.4 ng/mL. Transthoracic echocardiography (TTE) showed biventricular failure with ejection fraction (EF) 20% and an intra-aortic balloon pump (IABP) was placed for COVID-19 associated myocarditis prior to a tertiary care facility transfer.
On arrival, she was on four vasopressors despite IABP. Renal replacement therapy was initiated for acute kidney injury and she was cannulated for ECPELLA. Shortly after cannulation vasopressor doses decreased. Intravenous (IV) methylprednisolone was given for three days and tapered. She was decannulated on ECPD 10 with recovery of cardiac and renal function. She was discharged home on HD 21.
Case 2: A previously healthy 22-year-old male presented three days after COVID-19 diagnosis for fever, worsening dyspnea, and chest pain. He deteriorated, requiring intubation and three vasopressors. Labs notable for troponin 2.9 ng/mL, pro-BNP 33200 pg/mL, creatinine 6.9 mg/dL, lactate 14 mg/dL. TTE revealed biventricular failure, EF 20-25%, consistent with COVID-19 associated myocarditis. He was cannulated for ECPELLA on HD 1 and started on five days of IV methylprednisolone.
Hemodynamics improved, he was decannulated on ECPD 7 and extubated on HD 8. TTE on HD 14 showed cardiac recovery, with EF 55-60%. He was discharged home on HD 20.
Discussion: This highlights the success of ECPELLA and glucocorticoids in COVID-19 associated myocarditis in two young patients. ECPELLA has been previously described in myocarditis and may be important in early treatment of COVID-19 myocarditis in young patients. Glucocorticoids are increasingly used in patients with severe respiratory COVID-19 and its role in myocarditis remains to be seen. Clinicians should be aware of this presentation of COVID-19 and quickly request consultation from an ECMO center. Further investigation is paramount.