Case report
A 31-year-old male patient without comorbidities was admitted due to cardiogenic shock and pneumonia. He required orotracheal intubation, dobutamine and norepinephrine on the 2ndhospitalization day. On the 8th hospitalization day, worsening of hemodynamics led to necessity of intra-aortic balloon pump (IABP) and extracorporeal membrane oxygenation (ECMO).
Respiratory symptoms started 9 days before hospitalization. Nasopharyngeal SARS-CoV-2 reverse transcription polymerase chain reaction (RT-PCR) were performed on admission and 2ndday of hospitalization. Two SARS-CoV-2 RT-PCR in tracheal secretion were also performed on 3rd and 4th days, both negative. An IgM and IgG SARS-CoV-2 test was negative after 23 days of symptoms. Thoracic computed tomography scan (CT scan) suggested bacterial pneumonia (Figure 1). Echocardiogram showed severe left ventricular dysfunction (ejection fraction 24%) and moderate right ventricular dysfunction (RVD). Endomyocardial biopsy revealed diffuse hypertrophy and mild fibrosis. Cardiac magnetic resonance revealed no late gadolinium enhancement.
After initial support and antibiotics, the patient recovered from organ dysfunctions. He 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 on 83rd day of hospitalization. However, the patient presented fever in the operating room and next 3 days. He was extubated on 2nd postoperative day (POD) and was weaned off vasopressors. He also presented lymphopenia and C-reactive protein elevation (Table 1). Nasopharyngeal SARS-CoV-2 RT-PCR returned positive.
On 5th POD, the patient became hypoxemic requiring high flow nasal cannula (chest X-ray on Figure 2). He was on intravenous heparin since 2nd POD and antibiotics and corticosteroids were prescribed. Blood and tracheal secretion urine cultures returned negative. Echocardiogram revealed severe RVD. Hypotension and a drop on central venous saturation (Table 2) led to milrinone 0.75mcg/kg/min and dobutamine 20mcg/kg/min requirement.
On 10th POD endotracheal intubation was required. The patient experienced severe acute respiratory distress syndrome (ARDS) and multiple complications: shock requiring vasopressors, secondary bacterial pneumonia, hemothorax, catheter-related bloodstream infection and pneumothorax due to barotrauma. A CT scan performed on 34th POD revealed bilateral ground glass opacities, bilateral pneumothorax and consolidation (Figure 1.B). He had no thromboembolic events.
After 48 days of LVAD implantation, he was free from mechanical ventilation (MV) and inotropes. He was discharged from the intensive care unit after 51 days and from the hospital after 199 days of hospitalization.