Discussion
We present a case of a previously healthy young man who presented with cardiogenic shock of unknown etiology and respiratory failure with multiple negative SARS-CoV-2 RT-PCRs. He required LVAD implantation, and postoperative period was complicated by nosocomial SARS-CoV-2 pneumonia. To the best of our knowledge this is the first case report of COVID-19 in the immediate postoperative period of LVAD implantation. In this report we demonstrate that COVID-19 was associated with RVF in the setting of respiratory failure.
Right ventricular failure complicates 4-50% of LVAD implants12, and our patient was just in this delicate phase when he developed COVID-19. Although RVF can be a consequence of LVAD implantation, the 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.
The new coronavirus is associated with RVF by multiple mechanisms. Severe pneumonia and ARDS may lead to RVF14. The pathophysiology is multifactorial: hypoxia, vascular alterations, MV and hypercapnia all together may lead to pulmonary hypertension and RVF14. Myocardial injury has also been described in COVID-19, worsening biventricular function13. Our patient presented extreme troponin elevation after LVAD implantation, which could be due to the surgical procedure or a superimposed myocardial injury secondary to the new coronavirus.
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. Pre-specified demographic and prognostic data was collected. A total of 157 publications were found, and 8 publications met the selection criteria.
Fourteen patients are described (Table 3). The mean age was 62.7 years and 78.5% were male. The time since LVAD implant varied from 0.03 months to 6.8 years, and none of them happened in the immediate postoperative period. Five patients (35.7%) required MV and 3 patients (21.4%) died. Two patients (14.2%) had thromboembolic events. Six patients (42.8%) had mild symptoms, and three were followed as outpatients.
As expected, LVAD patients with COVID-19 had higher mortality than general population. Data from China shows a mortality rate of 2.3%2, while in this systematic review LVAD recipients had a fatality rate of 21.4%, probably because they have multiple comorbidities and live in a functionally immunocompromised state3. In contrast, our patient eventually recovered despite multiple complications, probably because of young age and lack of other comorbidities.
Mechanical ventilation was required in 35.7% of patients, while in general population only 14% present pneumonia and 5% require MV2. Despite frequent need for MV in LVAD patients and the concern about RVF in this population, in this systematic review only one patient presented RVF requiring inotropes6. This patient had mild symptoms of COVID-19 and did not present SARS-CoV-2 pneumonia or myocardial injury, so that RVD was not thought to be related to COVID-19.
The new coronavirus is also associated with high thromboembolic rates, and studies reported thromboembolism incidence of 25% in critical patients15. LVAD recipients in parallel are in intrinsic risk of pump thrombosis. This may raise a concern about thromboembolic events (TE) in this population. However, chronic anticoagulation may play a protective role since so far only 14.2% had TE while infected5, 8.
This study has limitations. All publications are case reports or case series. There is clinical heterogeneity between patients regarding age, type of LVAD and time since LVAD implantation. Mild cases of COVID-19 might be underrepresented. Despite these limitations, this is the first systematic review of LVAD and COVID-19. Also, the present case report illustrates the vulnerability of LVAD recipients regarding RVF in the perioperative setting.
In this systematic review, LVAD recipients with COVID-19 had a higher mortality and morbidity than general population. More study is needed to better understand COVID-19 in LVAD recipients.