Cardiogenic Shock in COVID 19 Fulminant Myocarditis Treated with V-A ECMO

INTRODUCTION: As COVID-19 pandemic spread, cases of involvement of the heart have been reported. CASE REPORT: A 47-year-old woman was admitted to the ICU of our hospital for severe cardiogenic shock. She was pyretic, hypoxemic, tachycardic and with reduction of voltages at ECG. TTE showed severe biventricular impairment with an EF of 20 %. Chest X-ray revealed interstitial edema (Fig.1). Invasive mechanical ventilation and inotropic support and empiric antibiotic therapy were set up. High levels of IL-6, lactate, TpnI, and pro-BNP and WBC emerged from laboratory exams (Fig.2).Testing for cardiotropic viruses came back negative, as well as hemocultures. BAL PCR resulted positive for SARS-CoV2. COVID-19 myocarditis was therefore diagnosed. Due to severe hypotension irresponsive to noradrenaline and adrenaline, IABP was placed. The following day, a pericardiocentesis was carried out for cardiac tamponade. Due to worsening of the general conditions, V-A ECMO was implanted. Corticosteroids were administered at high dosage. As cardiac function steadily improved and pro BNP and troponins decreased, vasopressor and inotrope were stopped, V-A ECMO was removed and IABP support was interrupted. Improvement of biventricular function was observed (EF 55 %), after 15 days the patient was transferred to the ward and after 25 days was discharged with heart failure therapy. SUMMARY: Currently, most of the ongoing research focuses on the respiratory complication of SARS-CoV2 and little is known about the management of COVID-19 myocarditis. In our experience, high dosage glucocorticoids, inotropes, and V-A ECMO improved the clinical conditions of the patient.