Discussion:
Cardiac injury caused by COVID-19 infection has been observed in early studies with a significantly increased risk of mortality. (2-3, 21) Increased risk of MI in the setting of a hypercoagulable state such as COVID-19, has been well documented in many cases. (4, 5) A possible pathophysiology has been reported by Esmail et al where COVID-19 causes a significant inflammatory reaction that manifest in the alveoli. The activation of epithelial cells, monocytes, and macrophages is caused by the release of inflammatory cytokines. Direct ACE2 receptor infection causes endothelial activation and dysfunction, TF expression, platelet activation, and elevated levels of vWF and FVIII, all of which contribute to thrombin production and fibrin clot formation. (6)
Specifically, cases have reported evidence for STEMI in the context of COVID-19. (7) When comparing non-COVID vs COVID STEMI patients, there is an increase in stent thrombosis and cardiogenic shock development after PCI in COVID patients. (8)
Currently, there are no published case reports in the context of COVID-19 resulting in STEMI with simultaneous cardiogenic shock leading to acute heart failure requiring LVAD.
Majority of the previous CAD cases have been found in males, whereas our report presents a female patient, suggesting sex may not be as significant of a risk factor for developing STEMI, as previously reported. (3,4) The cardiac risk factors in our patient were hypertension and hyperlipidemia, which are known risk factors for developing ACS; a similar trend has been observed in previously published reports (9). The patient in our study presented with VF, AKI, CS, and CHB; similar findings have been observed in previously published COVID-19 reports (1,4,10-12). Heart failure (HF) is most prevalent, accounting for 20% of outcomes among STEMI patients during the pandemic; these findings support our case of developing HF during hospitalization. (13) HF requiring LVAD implantation in a COVID non-STEMI patient has been reported, with a proposed algorithm for elective and urgent implantation based on coagulation and inflammatory markers (14). In our case, given the increased inflammatory burden and cardiac risk factors, it is important to approach with a higher index of suspicion of the common complications of STEMI.
These complications are life-threatening and require immediate management and interventions, as in our case where the patient first required PCI with LAD stent placement subsequently placed on ECMO. After further complications, the patient underwent AICD implantation and ultimately after worsening HF required LVAD. Similar findings and management for STEMI patients have been reported (15). Recent reports show cardiovascular complications of stent thrombosis and cardiogenic shock development after PCI in COVID-19 patients with STEMI in comparison to non-COVID 19 patients (16). One large multicenter study found that LVAD implantation is an effective management strategy and should be considered early for patients with myocardial infarction and low output states who do not respond to medical therapy. (17) Medical teams must be cognizant of these adverse events to efficiently identify and implement guidelines issued by European society of Cardiology (ESC) and American Heart Association (AHA), And American College of Cardiology (ACC) for appropriate management to reduce mortality (18-20).