Although relatively rare, there have been several case reports of COVID-19 infection causing acute myocarditis. These patients have required IV inotrope therapy and sometimes short-term veno-arterial ECMO support for bi-ventricular shock. Such was the case with a 64-year-old female patient from San Antonio who was successfully treated at Baylor University Medical Center.
Just days after becoming sick with COVID-19, the patient became critically ill. The ejection fraction of her left ventricle dropped to only 10 percent while her right ventricle functioned at 20 percent. She was admitted to a local hospital where physicians inserted an intra-aortic balloon pump and placed her on several medications to support her heart. However, it was quickly discovered she needed to be placed on extracorporeal membrane oxygenation (ECMO).
Because she was considered too high risk for ECMO care in San Antonio, a call was made to the Rapid ECMO Deployment (RED) Team at Baylor University Medical Center in Dallas. The survival rate at Baylor Dallas for patients with COVID-19 who are put on ECMO is 71 percent.
“When we put COVID patients on ECMO, 95 percent of the time it is veno-venous ECMO to support the lungs,” says Dan Meyer, MD, Chief of Cardiac Transplantation and Advanced Cardiac Circulatory Support, Baylor Dallas. “But when patients need support for both the heart and lungs, we also have extensive veno-arterial experience.”
The RED team – an ECMO physician, cardiac ICU nurse with specialized ECMO training and a perfusionist – flew to San Antonio where they placed the patient on ECMO. To safely transport patients with COVID-19, the team developed additional safeguards to protect the health care team, as well as ambulance and flight crews. To date, the team has done five COVID ECMO transports with no health care provider exposure.
“The vast majority of patients have to be intubated and put on a ventilator prior to being put on ECMO,” says Gary Schwartz, MD, Director of Extracorporeal Membrane Oxygenation, Baylor Dallas. “In rare cases, we put patients on ECMO but off a ventilator, awake and breathing on their own while being transported on a fixed-wing aircraft. It would be difficult to come up with a more challenging scenario.”
After 72 hours on ECMO, the patient regained almost normal heart function at 40 percent ejection fraction. She spent another few weeks in the hospital where her heart recovered completely. She was then discharged to go home to San Antonio.
“In treating hospitalized COVID-19 patients, the first goal is to keep them off a ventilator,” Dr. Meyer says. “When they do go on a ventilator, we try to manage them with techniques such as proning. When they fail those maneuvers, then ECMO may be considered for a select group of patients.”
To select patients who could potentially have good outcomes on ECMO and to use a scarce resource appropriately, the Baylor Dallas team developed strict patient criteria: limited comorbidities, age limit of 60-65, BMI less than 40 and no longer than 10 days on a ventilator. In normal times at Baylor Dallas, two ECMO specialist physicians must agree that the patient is a candidate for ECMO. For COVID-19 patients, an ad hoc committee of two ECMO physicians plus an intensivist must agree to put a patient on ECMO. “COVID myocarditis is very scary and potentially devastating,” Dr. Schwartz says. “High-risk cases can be managed effectively if recognized early enough and treated appropriately.”