Use Of Prone Positioning In Patients With Left Ventricular Assist Devices

BACKGROUND: Use of prone position for treatment of acute respiratory distress syndrome (ARDS) has been effective for patients with COVID-191,2. While case reports exist on proning patients on extracorporeal membrane oxygenation (ECMO) there are limited reports of the safety and efficacy in patients with durable left ventricular assist devices (LVAD). 3,4. CASE STUDY: Patient is a 76 year old Hispanic male with a past history for ischemic cardiomyopathy requiring HeartMate III (Abbott, IL) LVAD who presented to the emergency dept in January 2021 with two day history of dyspnea on exertion, chills and insomnia. He reports no known contact with COVID individuals. In the ED, noted severe hypoxia on arterial blood gas (ABG) pH 7.343, pO2 51.5. O2 saturation was 86% and chest x-ray revealed bilateral infiltrates suggestive of COVID 19 pneumonia. He was placed on a nonrebreather (NRB) mask and empiric antibiotics started. A nasopharyngeal swab was PCR positive for COVID19 and he was admitted for management. A repeat ABG on NRB had an increase of pO2 172. He was started on remdisivir and convalescent plasma. As part of management, was proned for 12 hours daily. The LVAD driveline was supported with pillows to avoid pressure and trauma. The LVAD controller was placed on the patient side for emergent access. Peripheral oxygenation saturation remained above 93% and his respiratory status continued to improve. He was cleared for discharge on day 6. No adverse events were noted on LVAD interrogation and he had no ill effects to the driveline. DISCUSSION: Prone positioning has been integral for patients with COVID 19 to decrease intubation with severe ARDS. Patients with a LVAD already have significant cardiac disease and thus important to avoid further decompensation with intubation, VA ECMO, and cardiac demise. Driveline infections can lead to high morbidity and mortality. Patients with COVID 19 are at a high risk for poor skin care and pressure injuries. Supporting the controller and driveline allowed for decrease in pressure injury and trauma at the driveline site. This allowed our ability to prone our patient and properly oxygenate which was tolerated. REFERENCES: 1. Coppo,A., Bellani, G., Winterton, D., DiPerro, M., Soria, A., et al. 2020. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study. Lancet Respiratory Medicine. 8 (8) 765-774. 2. Damarla M, Zaeh S, Niedermeyer S, et al. Prone Positioning of Nonintubated Patients with COVID-19. Am J Respir Crit Care Med. 2020;202(4):604-606. doi:10.1164/rccm.202004-1331 3. LELehr, A., Smith, D., Toy, B., Goldenberg, R., Brosnahan, S. 2020. Successful use of an automated proning system to achieve prone positioning in a patient with severe ARDS requiring veno-venous ECMO. Respiratory Medicine Case Reports. 31. 101315. 4.Rajagopal, K., Keller, S., Akkanti, B., Bime, C., Loyalka, P et al. 2020. Advanced pulmonary and cardiac support of COVID-19 patients: emerging recommendations from ASAIO- a living working document. Circulation