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.