key: cord-0808239-dhy7kdan authors: Belfort, Deborah de Sá Pereira; Biselli, Bruno; Ávila, Mônica Samuel; Lira, Maria Tereza Sampaio de Sousa; Galas, Filomena Regina Barbosa Gomes; Steffen, Samuel Padovani; Gaiotto, Fabio Antonio; Jatene, Fabio Biscegli; Bocchi, Edimar Alcides; Ferreira, Silvia Moreira Ayub title: COVID‐19 complicating perioperative management of LVAD implantation: A case report and systematic review date: 2021-06-06 journal: J Card Surg DOI: 10.1111/jocs.15690 sha: 0e1a1eaa3eb2d4e30462fcbd31618efa39dc32d6 doc_id: 808239 cord_uid: dhy7kdan The coronavirus 2019 disease (COVID‐19) affected 125 million people worldwide and caused 2.7 million deaths. Some comorbidities are associated with worse prognosis and left ventricular assist device (LVAD) recipients are probably part of this high‐risk population. We report a 31‐year‐old male patient who developed COVID‐19 during LVAD implantation. His postoperative period was complicated by severe pneumonia and mechanical ventilation (MV) leading to right ventricular failure (RVF) and inotrope necessity. He experienced multiple complications, but eventually recovered. We present a systematic review of LVAD recipients and COVID‐19. Among 14 patients, the mean age was 62.7 years, 78.5% were male. A total of 5 patients (35.7%) required MV and 3 patients (21.4%) died. A total of 2 patients (14.2%) had thromboembolic events. This case and systematic review suggest LVAD recipients are at particular risk of unfavorable outcomes and they may be more susceptible to RVF in the setting of COVID‐19, particularly during perioperative period. The coronavirus 2019 disease (COVID-19) affected 125 million people worldwide and caused 2.7 million deaths so far. 1 Some conditions such as diabetes, hypertension, heart failure and coronary artery disease are associated with worse prognosis. 2 Left ventricular assist device (LVAD) recipients are probably part of this high-risk population since they usually have multiple comorbidities and live in a functionally immunocompromised state. 3 There are few data on LVAD recipients and COVID-19, and most cases occurred months or years after LVAD implantation. [4] [5] [6] [7] [8] [9] [10] [11] We present a case of a patient who presented fever during LVAD implantation as the first manifestation of COVID-19 who developed critical disease. A 31-year-old male patient without comorbidities was admitted due to dyspnea, cough, fever, and hypotension 9 days before hospitalization. Initial workup revealed bacterial pneumonia ( Figure 1A ) on thoracic computed tomography scan (CT scan) and severe left ventricular dysfunction (ejection fraction 24%) and moderate right ventricular dysfunction (RVD) on echocardiogram. Troponin was negative and brain natriuretic peptide was elevated. Multiple negative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcription polymerase chain reaction (RT-PCR) were performed on admission, 2nd, 3rd, and 4th days of hospitalization. An immunoglobulin M and On the 2nd hospitalization day, he presented cardiogenic shock requiring orotracheal intubation, dobutamine and norepinephrine. On the 8th hospitalization day, he worsened hemodynamics, requiring intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO). The presumed etiology of heart failure was dilated cardiomyopathy, since endomyocardial biopsy revealed diffuse hypertrophy and mild fibrosis and cardiac magnetic resonance revealed no late gadolinium enhancement. Coronary evaluation was not performed due to absence of fibrosis, negative troponin and no risk factors for atherosclerosis. After initial support and antibiotics, the patient was extubated and ECMO was weaned off after 9 days. However, he persisted dependent on dobutamine and IABP, and LVAD implantation was planned as a bridge to transplant. Right heart catheterization revealed no pulmonary hypertension (Table 1) . A Heart Mate 3 was successfully implanted on-pump lately on 83rd day of hospitalization. However, the patient presented fever in the operating room and for the next 3 days. He was extubated on 2nd postoperative day (POD) and was weaned off vasopressors without RVD on echocardiogram. He also presented lymphopenia and C-reactive protein elevation (Table 2) . Nasopharyngeal SARS-CoV-2 RT-PCR returned positive, probably due to nosocomial transmission before LVAD implantation. On 5th POD, the patient became hypoxemic requiring high flow nasal cannula (chest X-ray in Figure 2 ). He was on intravenous heparin since 2nd POD and antibiotics and corticosteroids were pre- which in 10%-25% of cases may lead to RVF. 12 The pathophysiology is multifactorial: hypoxia, vascular alterations, MV and hypercapnia may lead to pulmonary hypertension and RVF. 12 Second, the new coronavirus also contributes to pulmonary hypertension and RVF causing microthrombi in pulmonary vasculature due to a prothrombotic state. 13 Finally, the virus can also cause direct cardiovascular conditions such as arrhythmias, acute coronary syndrome and acute myocardial injury, worsening biventricular function and leading to higher mortality. 14 Right ventricular failure can be a consequence of LVAD implantation in 4%-50% of cases. 15 However, our patient did not present clinical or echocardiographic signs of RVF until he required noninvasive MV. Therefore, COVID-19 probably had a main contribution to RVF in this case. A systematic review was performed searching PubMed and MEDLINE and using the keywords "LVAD" and "COVID-19" for comparison with this case. The selection criteria were case reports or case series of LVAD recipients and positive SARS-CoV-2 RT-PCR. Prespecified demographic and prognostic data was collected. A total of 157 publications were found, and 8 publications met the selection criteria. A total of 14 patients are described ( WHO Coronavirus Disease (COVID-19) Dashboard Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention Quantitative changes in T-cell populations after left ventricular assist device implantation: relationship to T-cell apoptosis and soluble CD95 The imperfect cytokine storm: severe COVID-19 with ARDS in a patient on durable LVAD Support Characteristics and outcomes of patients with a left ventricular assist device with coronavirus disease-19 COVID-19 infection in left ventricular assist device patients Contributory role of positron emission tomography in a left ventricular assist device recipient at the time of COVID-19 pandemic Successful management of COVID-19 and associated coagulopathy in a patient with durable left ventricular assist device Management of COVID-19 in a durable left ventricular assist device recipient: a continuity of care perspective Novel coronavirus disease 2019 in a patient on durable left ventricular assist device support Predisposition or Protection?: COVID-19 in a patient on LVAD support with HIV/AIDS Right ventricular dysfunction during acute respiratory distress syndrome and veno-venous extracorporeal membrane oxygenation Thrombosis risk associated with COVID-19 infection. A scoping review Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China Derivation and validation of a novel right-sided heart failure model after implantation of continuous flow left ventricular assist devices: The EUROMACS (European Registry for Patients with Mechanical Circulatory Support) Right-Sided Heart Failure Risk Score Death TEE RVF