key: cord-0848536-qrhl0uor
authors: Hays, Brandon S.; Northrop, Michael S.; Shetty, Avinash K.; Petty, John K.; Ootaki, Yoshio
title: Critical COVID-19 complicating recovery from surgical repair of congenital heart disease
date: 2021-05-06
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2021.04.065
sha: 8b5178384189dfa3cb1a6bf5cf7743afc605241b
doc_id: 848536
cord_uid: qrhl0uor

This case highlights the need for accurate and rapid testing for SARS-CoV-2 and also underscores the need for caregivers to remain vigilant for COVID-19 in the post-operative setting despite negative pre-operative testing.

Pre-operative testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is recommended and has become routine clinical practice. We discuss an infant undergoing repair of congenital heart disease with negative pre-operative testing who subsequently tested positive for SARS-CoV-2 and developed acute respiratory distress syndrome from acute novel coronavirus 2019 disease . POD4 he developed fever, acute oxygen desaturations and decreased peripheral perfusion. He became significantly fluid-positive despite aggressive attempts at diuresis and had elevated central venous pressure to 20 mmHg. Laboratory data were notable for leukopenia, thrombocytopenia, and an elevated procalcitonin at 3.9 ng/mL. Blood cultures were obtained and broad-spectrum antibiotics were empirically started. Stress dose hydrocortisone was given due to a concern for adrenal insufficiency. The patient's mother and grandmother both also subsequently tested positive for SARS-CoV-2 by PCR; the mother recalled having dizziness and fever on the day of surgery and also reported having anosmia and loss of taste. CXR showed 'white out' of the left lung as is commonly seen in acute respiratory distress syndrome (ARDS) supported by ECMO 2 (Figure 2) . The ECMO cannula was confirmed to be in good position by echocardiogram. The patient was treated with a 10-day course of Remdesivir and dexamethasone guided by the pediatric Infectious Disease consultant. He was also treated for six weeks with intravenous ceftriaxone for possible pneumococcal endocarditis. Over time, his CXR and respiratory function improved on ECMO and continuous renal replacement therapy (CRRT), and he was successfully decannulated from ECMO after 9 days of support (Figure 3) . He was extubated to nasal cannula on POD24 and weaned to room air on POD35. He was unable to take adequate oral feedings without aspiration and a gastrostomy tube was placed on POD44. He was discharged home on POD50.

We report a case of an infant undergoing corrective repair of congenital heart disease whose postoperative course was complicated by acute COVID-19, pneumococcal bacteremia and ARDS for which the patient was successfully supported with venovenous ECMO. 3 To our knowledge, neither a postoperative course complicated by SARS-CoV-2 infection nor associated pneumococcal sepsis have been reported in a pediatric patient. Our patient is also the first known reported case of ECMO utilization after open heart surgery in a child whose course was complicated by acute respiratory failure from COVID-19.

This case illuminates just one of the many new challenges in caring for children during a pandemic:

unreliable pre-operative testing.

While pre-operative testing for SARS-CoV-2 is routinely performed, the logistics and timing appear to be problematic. Our patient likely contracted SARS-CoV-2 one or two days preoperatively, and following a typical incubation period, became symptomatic approximately five days after infection (POD3-4). The source of our patient's exposure to SARS-CoV-2 remains unclear, though he most likely contracted it from his family members.

Reliable testing with rapid results needs to be ubiquitous. Additionally, pre-operative testing algorithms need to be adjusted to mandate testing as close as possible to the time of the procedure in order to minimize the window of preoperative risk for infection. In our institution, testing is mandated to occur five to seven days prior to a procedure with patient "self-isolation" for seven days prior. Unfortunately, complete isolation is not always possible for a child or family. This long pre-operative testing timeframe is fraught with risk of infection in a pediatric patient during a growing pandemic. While such risk will be impossible to completely eliminate, reducing the window for exposure is paramount.

Our case also illustrates particular clinical challenges in caring for a patient with congenital heart disease during a respiratory virus pandemic. A patient with TOF with absent pulmonary valve and severe branch pulmonary artery dilation is known to have an increased risk for post-operative respiratory compromise due to congenital tracheobrochomalacia. 4 Our patient did well for two to three days post- operatively, but then quickly decompensated. The etiology of his decompensation was unclear at the time given the presumption of negative COVID-19 status. The delayed diagnosis of SARS-CoV-2 infection led to a delay in treatment, which could have potentially curbed his inflammatory response and respiratory failure. Additionally, the delay in diagnosis exposed many hospital staff members to the virus who subsequently were required to quarantine for 14 days.

ECMO use has been previously reported to support multi-system organ failure in children with

Multisystem Inflammatory Syndrome in Children (MIS-C) associated with SARS-CoV-2. 5 

Medium-term outcomes after implantation of expanded polytetrafluoroethylene valved conduits

Coronavirus disease 2019 (COVID-19): A systematic review of imaging findings in 919 patients

Allocation of resources and development of guidelines for extracorporeal membrane oxygenation (ECMO): Experience from a pediatric center in the epicenter of the COVID-19 pandemic

Surgical treatment of absent pulmonary valve syndrome associated with bronchial obstruction

ECMO support in SARS-CoV2 multisystem inflammatory syndrome in children in a child

Veno-venous extracorporeal membrane oxygenation for COVID-19-associated pediatric acute respiratory distress syndrome

COVID-19 respiratory failure: ECMO support for children and young adult patients