CardioNerds (Amit Goyal & Daniel Ambinder) discuss a case report of COVID myocarditis and cardiogenic shock with Dr. Travis Howard and Dr. Zach Il’Giovine, cardiology fellows at the Cleveland Clinic. Dr. Nir Uriel, Professor of Medicine at Columbia University and Director of Advanced Heart Failure and Transplant at NewYork-Presbyterian Hospital Network in New York joins to discuss COVID-19 myocarditis and management of cardiogenic shock.
The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.
Healthy and physically fit incarcerated 49M who presents with 2 weeks of fevers, myalgias, and SOB. His past medical history includes GSW to abdomen, psoriasis not currently on medications, prior tobacco and alcohol abuse. Transferred for undifferentiated shock on norepinephrine, and was found to be in sinus tachycardia to 110 bpm, hypotensive despite vasopressor infusions with labs showing a hyperinflammatory state, multi-organ failure, and eventually found to be COVID+. The patient quickly progressed into refractory cardiogenic shock requiring VA-EMCO, as well as Impella placement for LV unloading. The patient underwent endomyocardial biopsy with electron microscopy which was notable for COVID virions in the myocardium and was diagnosed with COVID myocarditis. Interestingly, his chest CT showed normal lung parenchyma and therefore presented as isolated cardiac involvement of COVID-19. The patient improved with tocilizumab, IVIG, and steroids.
The CardioNerds 5! – 5 major takeaways from the #CNCR case
- Diagnose Cardiogenic Shock at the Bedside!
- Exam: Narrow Pulse Pressure, Labored Breathing, Cheyne-Stokes Respirations, Abdominal Bloating/Nausea, Cool Extremities, Oliguria, Altered Mental Status
- If PAC available, low central (PA) mixed venous saturation (<55-60%) suggestive* of cardiogenic shock
- COVID-19 can cause myocardial injury through several mechanisms
- Ischemic – Supply/Demand Mismatch, Acute Plaque Rupture
- Nonischemic – Stress Cardiomyopathy, Lymphocytic Infiltration, Direct Viral Cardiomyocyte Injury, Bystander Injury from Systemic Inflammation
- Different forms of mechanical support give varying levels of cardiac output and pulmonary support
- Consider VA-ECMO in refractory cardiogenic shock, especially if there is evidence of biventricular failure +/- pulmonary compromise
- VA-ECMO may require “LV unloading” when there is high afterload leading to pulmonary congestion and/or stasis of blood flow in the LV
- Dexamethasone in Hospitalized Patients with COVID-19
- Non-invasive imaging in the diagnosis of acute viral myocarditis
- Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness: The ESCAPE Trial
- Mechanical Circulatory Support Devices for Cardiogenic Shock: State of the Art
- Left ventricular distension and venting strategies for patients on venoarterial extracorporeal membrane oxygenation
- Remdesivir for the Treatment of Covid-19 – Preliminary Report
- Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients With Severe and Life-threatening COVID-19: A Randomized Clinical Trial
- CardioNerds Myocarditis page
- Talking Tall Rounds Epsiode
- Tall Rounds Conference