key: cord-289859-b1k9uyp6
authors: Hodges, Kevin; Mubashir, Mujtaba; Insler, Joshua; Estep, Jerry; Hsich, Eileen; Tong, Michael; Insler, Steven; Soltesz, Edward
title: Successful management of COVID‐19 and associated coagulopathy in a patient with durable left ventricular assist device
date: 2020-08-13
journal: J Card Surg
DOI: 10.1111/jocs.14937
sha: 
doc_id: 289859
cord_uid: b1k9uyp6

Patients with durable left ventricular assist devices pose special problems for management in the setting of COVID‐19 infection. We describe the successful management of a 44‐year‐old man with severe COVID‐19 infection and HeartMate 3 left ventricular assist device. His course was complicated by cytokine storm and COVID‐19‐associated coagulopathy. We describe our institutional protocol for managing COVID‐19 infection in patients on mechanical circulatory support, focusing on the need for a thoughtful, multidisciplinary approach.

Patients with durable left ventricular devices (LVADs) pose special problems for management in the setting of COVID-19 infection.

Among these is balancing the risk of bleeding and thrombosis in the setting of COVID-19 associated coagulopathy, which is a welldescribed complication of COVID-19 infection. [1] [2] [3] We present the case of a patient with ischemic cardiomyopathy supported by durable LVAD who developed severe COVID-19 infection with acute respiratory distress syndrome complicated by coagulopathy. We focus on the interdisciplinary approach used to successfully manage this complex patient. After consultation with vascular surgery, it was deemed that the risk for surgical intervention was prohibitive. Lower extremity warming was initiated along with continued therapeutic anticoagulation. The patient's lower extremity exam improved over the course of 2 weeks with reestablished pedal Doppler signals.

During this period, the patient had nasopharyngeal bleeding, gross hematuria, and retroperitoneal hematoma requiring transfusion. Anticoagulation was held for 6 days in the setting of retroperitoneal hematoma without active reversal (hospital day 18-24). The patient did not develop signs of recurrent arterial thrombosis in the absence of therapeutic anticoagulation.

The patient was extubated after 11 days of mechanical ventilation (hospital days 2-13) and noted to have negative COVID testing on hospital day 19 and 23. The patient continued to improve and was discharged home on hospital day 31.

Management of COVID-19 infection in the context of durable LVAD support requires careful institutional planning and a multidisciplinary approach. We recommend that such patients be managed at institutions with robust surgical and medical heart failure programs, as well as expertize in infectious disease and an array of subspecialty services. We also recognize the challenges in transferring patients with COVID-19. Therefore, our recommendations is that LVAD patients with COVID-19 be treated at the nearest center with appropriate resources and expertize.

Likewise, management of COVID-19-infected LVAD patients requires a careful balance between isolation precautions and availability of expert clinicians. Our institution has designated an 18-bed cardiothoracic intensive care unit as an isolation unit for COVID-19infected patients who require mechanical circulatory support. Here, board-certified cardiothoracic intensive care physicians lead virtual multidisciplinary rounds with medical and surgical heart failure specialists via teleconference on mobile workstations at the bedside. This allows our heart failure specialists to jointly manage these patients while maintaining strict isolation to safeguard other patients, including heart and lung transplant recipients.

COVID-19 is often complicated by the development of coagulopathy, characterized by inappropriate activation and consumption of coagulation factors, thrombocytopenia, elevated D-dimer, and prolonged prothrombin time. 1 Elevated D-dimer (> 1 µg/mL) has been reported to be a strong, predictor of death in these patients. 4 Unlike with disseminated intravascular coagulation in sepsis or trauma, thrombocytopenia is often mild and is not considered a predictor of mortality. 5,6 Based on these observations, the International Society on Thrombosis and Haemostasis (ISTH) recommends frequent F I G U R E 1 Chest radiograph demonstrating bilateral interstitial pulmonary opacities consistent with COVID-19 pneumonia. Also in picture are sternal wires from previous sternotomy, implantable cardioverter-defibrillator (ICD), and HeartMate 3 left ventricular devices F I G U R E 2 Trends in D-dimer, fibrinogen, and platelets during the first 22 days of hospitalization. A sharp rise in D-dimer was noticed at the time of left foot ischemia from presumed intravascular thrombosis (black arrows). In the subsequent days, there was a sharp decline in platelets and fibrinogen measurement of D-dimer, prothrombin time, and platelet counts in all hospitalized patients being treated for COVID-19. 4, 5 These findings have prompted interest in the use of anticoagulation for management and prophylaxis in COVID-19 patients. In particular, low molecular weight heparin may have benefit due to its anticoagulant and anti-inflammatory properties. 4 There is emerging evidence that a cytokine storm-driven in part by IL-6 may play an important role in the pathogenesis of severe COVID-19 infection. Tocilizumab is an IL-6 inhibitor that has generated attention as a potential therapy in this patient group. 7 We utilized this agent empirically in our patient in an effort to limit the severity of cytokine storm. Whether this or other cytokine modulators prove effective in large series is the subject of ongoing investigations that will more clearly define the importance of cytokine storm in the pathogenesis of severe COVID-19 infection.

Dr Hodges discloses a financial relationship with Atricure, Dr Estep with Abbott and Medtronic, Dr Tong with Abbott and Abiomed, Dr Soltesz with Abbott, Atricure, Edwards, and Abiomed. The other authors have nothing to disclose.

According to the Cleveland Clinic Institutional Review Board: a case report for 1 to 3 patient(s) is considered a non-research activity because it is not a systematic investigation designed to contribute to generalizable knowledge. Therefore, CCF IRB approval is not required however; the ethical principle of obtaining consent is relevant whether or not the case report meets the formal definition of human subject research. Accordingly, this case report was discussed with the patient and verbal consent was obtained for publication and witnessed by two Cleveland Clinic employees.

http://orcid.org/0000-0002-7724-5271

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Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy

Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia

Successful management of COVID-19 and associated coagulopathy in a patient with durable left ventricular assist device