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.