A Rare Case of COVID-19 Induced Multisystem Inflammatory Syndrome in Adult (MIS-A) Requiring Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO)

INTRODUCTION: MIS-A is a rare COVID-19 induced condition defined by fever, new-onset severe cardiac illness, rash, encephalopathy, and elevated inflammatory markers in the setting of positive serum COVID-19 antibodies. This inflammatory cascade can cause significant biventricular dysfunction and subsequent cardiogenic shock. Patients with MIS-A can require temporary cardiac support including VA-ECMO. We present a case of a patient requiring VA-ECMO secondary to MIS-A induced heart failure and cardiogenic shock, with eventual myocardial recovery. CASE REPORT: 30-year-old male with type two diabetes was admitted with acute hypoxic respiratory failure, multiorgan failure, acute systolic biventricular heart failure, and COVID-19 infection four weeks prior. He was intubated and placed on vasopressors, antibiotics, and steroids for concerns for combined cardiogenic and septic shock. TTE noted global hypokinesis and 10-15% EF. EKG was sinus rhythm. He had mildly elevated troponins. Inflammatory markers including D-dimer, fibrinogen, and IL-6 were highly elevated. Despite antibiotics and supportive measures, the patient developed worsening hypoxia and hypotension. IVIG was also initiated, with deferral of plasmapheresis. At this time, MIS-A was suspected. The patient was approved for VA-ECMO as a means for bridging to cardiac recovery. He required VA-ECMO for four days, with ability to decannulate, extubate, and wean off vasopressors. COVID-19 antibody testing was positive. Infectious workup was negative, with the patient transitioned off antibiotics and steroid regimen after completing treatment course. Inflammatory markers improved. Repeat TTE noted 44% EF with improved biventricular function. Cardiac MRI one day later, noted 61% EF without evidence of scar, myocarditis, or perimyocarditis. He was discharged home after a total of 8 days of treatment with follow-ups scheduled. SUMMARY: This case highlights a severe presentation of MIS-A and showcases the benefit of VA-ECMO as a bridge to myocardial recovery. VA-ECMO has been shown to improve in-hospital survival and serve as a mechanism for cardiac recovery in acutely ill patients. Long-term cardiac effects and recovery rates post COVID-19 induced MIS-A remain unknown.