Case Report
A 57-year-old female with a history of hypertension, hyperlipidemia, prior COVID-19 infection in April 2020 and was treated for the infection, who now presented to the hospital in June of 2020 with a complaint of chest pain, found to have STEMI on EKG with associated ventricular fibrillation (VF) and pulseless electrical activity arrest for 14 minutes prior to achieving ROSC (Figure 1). During CPR, the patient required desynchronous cardioversion with amiodarone, lidocaine, and sodium bicarbonate. In the catheterization lab, LAD was stented and the patient was placed on extracorporeal membrane oxygenation (ECMO) for 4 days. The course was complicated by cardiogenic shock (CS) and complete heart block (CHB) for which the patient underwent automated implantable cardioverter defibrillator (AICD) implantation by electrophysiologists. She also developed bilateral hemothoraces and rib fractures as a result of CPR which required bilateral chest tube placement. Moreover, the patient developed catheter-associated Hafnia Alvei UTI, treated with cefepime and a short course of vancomycin until blood culture yielded.
After PCI, the patient developed severe oliguric acute kidney injury (AKI) requiring hemodialysis, shock liver, pulmonary edema and failure to wean off ventilator with progressively decreasing cardiac output thus developing CS. Post PCI transthoracic echocardiogram (TTE) revealed LVEF 27% with anteroapical and inferoseptal hypokinesis, mild to moderate mitral regurgitation and indeterminate diastolic dysfunction.
Right heart catheterization revealed severe volume overload, severe pulmonary hypertension, low cardiac output, right heart dysfunction along with echo showing severe LV dysfunction with an EF of less than 20%. Femoral intra-aortic balloon pump was placed in July 2020 and transitioned to axillary intra-aortic balloon pump 3 days later. She failed to be weaned off of the balloon pump and was seen by the heart failure team who determined to place her on LVAD. LVAD Heart Mate 3 was inserted on cardiopulmonary bypass in July 2020. Subsequent echo showed a loculated pericardial effusion that did not require intervention. After a failed extubation trial, tracheostomy was performed. At this time, she was well-diuresed with Lasix infusion followed by IV Lasix boluses while remaining on low dose epinephrine. During her post LVAD stay she developed A. fib and was started on digoxin and amiodarone (Figure 2).In early August, she was weaned off pressors and the ventilator; the patient’s symptoms improved and subsequently discharged on: amiodarone, digoxin, beta-blockers, prasugrel, warfarin, spironolactone and lisinopril.
The patient was discharged to a rehabilitation facility where her symptoms gradually improved, there her medications’ better optimized and was subsequently discharged home in September 2020.