A 55-year-old male patient with no known comorbidities developed cough, edema, and dyspnea with progressive worsening approximately 2 months earlier. There were no viral or infectious prodromes. The patient was initially treated for pneumonia in another hospital with piperacillin-tazobactam and clarithromycin. A respiratory viral panel including influenza, respiratory syncytial virus, and SARS-CoV-2 was negative for all viruses.
An echocardiogram was performed during hospitalization and showed significant dilation of the cardiac chambers (left ventricle: 70 mm; right ventricle: 36 mm) with marked increase of the left atrium (left atrial volume index of 74 cm2). The absence of tricuspid regurgitation did not allow for measurement of pulmonary artery systolic pressure.
After 4 weeks of hospitalization, the patient’s clinical condition continued to deteriorate despite heart failure treatment. He developed systemic and pulmonary congestion resistant to diuretics, progressive worsening of renal function, increased liver transaminases, hypotension, and clinical signs of low cardiac output. The patient was started on 10 mcg/kg/min dobutamine and referred to our hospital for evaluation by the heart transplant team.
The patient arrived in our hospital in INTERMARCS II cardiogenic shock and sinus tachycardia, with a heart rate of 122. He also had low blood pressure, poor peripheral perfusion, anuria, and anasarca, requiring immediate continuous hemodialysis. The use of a Swan-Ganz catheter identified the following: cardiac index 1.4 L/min/m2, PAP 32/23 mm Hg, PAOP 21, CVP 12, SVR 1,066 dynes/seconds/cm5, and PVR 148 dynes/seconds/cm5 (
An intra-aortic balloon pump (IABP) was inserted, but there was poor clinical response. The patient became severely hypotensive, with a reduced level of consciousness, progressive increases in lactate levels, and signs of liver dysfunction despite the use of 20 mcg/kg/min dobutamine, 0.1 mcg/kg/min norepinephrine, and 1:1 IABP support. Orotracheal intubation was required.
Due to the patient’s deterioration to INTERMACS I cardiogenic shock, we implanted a temporary mechanical circulatory assist device (peripheral VA-ECMO via the femoral artery). After clinical stabilization, an evaluation protocol for heart transplantation was initiated. The IABP was maintained to prevent LV hyperdistention, whereas continuous hemodialysis was maintained with the goal of aggressive negative fluid balance attainment (
After VA-ECMO implant, the patient progressed with rapid hemodynamic improvement and normalization of tissue perfusion and lactate levels and was extubated after 48 hours. There was also improvement of renal function, with discontinuation of renal replacement therapy after 7 days, and normalization of liver function and transaminases.
After 1 week on circulatory support, the patient was placed on the heart transplant waiting list with a priority status. After 14 days, the patient underwent a heart transplant, but there was severe right ventricular dysfunction during VA-ECMO weaning, thus we decided to maintain VA-ECMO until right ventricular function was recovered. On postoperative day 4, right ventricular function was completely stabilized, and the patient was successfully weaned off VA-ECMO. The patient was discharged from the intensive care unit on postoperative day 9 and from the hospital on postoperative 18 in good general condition for outpatient follow-up.
Pathological examination of the surgical specimen showed signs of lymphocytic myocarditis, dilated heart disease, and arterial thrombosis. Immunohistochemistry and viral investigation were not performed due to limitations in the pathology service.