Analysis Paralysis: Transition to HeartMate 3 Left Ventricular Assist Device Despite Multiple Complications from COVID-19

INTRODUCTION: We present a case of a 39 year old male with nonischemic cardiomyopathy who was successfully bridged to HeartMate3 Left Ventricular Assist Device (LVAD) despite multiple life threatening complications secondary to Covid-19. CASE REPORT: 39-year-old male with past medical history notable for tobacco abuse and recently diagnosed non-ischemic cardiomyopathy presented to our institution with NYHA Class IV symptoms and was found to be in cardiogenic shock. On admission Covid-19 PCR was negative. He initially responded to the initiation of inotropic support and aggressive diuresis with normalization of his end-organ function and improvement in his symptoms over three days. He suddenly experienced rapid hemodynamic decline necessitating escalation of inotropic and mechanical circulatory support with VA ECMO and Impella 5.5. On that day, his wife felt unwell and was found to be positive for Covid-19. The patient's Covid-19 PCR was repeated and also positive. He underwent treatment with Regeneron. His hospital course was further complicated by multiple sequelae of Covid-19 including pneumonia, acute renal failure necessitating hemodialysis (HD), and Guillain Barre Syndrome (GBS) presenting with bilateral ascending paralysis extending to his hip flexors, improved with intravenous immune globulin (IVIG) therapy. Over a period of two weeks, he demonstrated improvement and was weaned from VA ECMO to Impella 5.5. Unfortunately, he was unable to tolerate weaning the Impella 5.5. He was aggressively rehabilitated. After extensive multidisciplinary discussion, LVAD implantation was recommended to the patient. Following insertion of a HeartMate3 LVAD, the patient demonstrated renal recovery and ongoing improvement in physical ability. He was discharged to an acute rehabilitation facility and was subsequently discharged home. He will be monitored for listing for cardiac transplantation pending abstinence from tobacco use. SUMMARY: Covid-19 can present with multiple life threatening complications that can add novel challenges to the management of patients with stage D cardiomyopathy. Despite complications of acute renal failure and paralysis secondary to GBS from Covid-19, our patient was successfully supported with temporary mechanical circulatory support, aggressively rehabilitated, and transitioned to a durable HeartMate 3 LVAD.