Mechanical Circulatory Support in Refractory Cardiogenic Shock

July 9, 2020

Extrapolations for COVID-19 from Influenza Virus-Related Myocarditis

Professor Dr. Andreas Schäfer and colleagues recently published a paper in the European Respiratory Journal titled “Mechanical Circulatory Support in Refractory Cardiogenic Shock due to Influenza Virus-Related Myocarditis.” Dr. Schäfer discusses the results of this paper and implications for COVID-19 with Dr. Seth Bilazarian. Dr. Schäfer is vice chair of cardiology at the Hannover Medical School, and the director of the cardiac arrest center in advanced heart failure in Hannover, Germany.

In this paper, 7 patients with severe cardiogenic shock—many with biventricular failure—and myocarditis from 2 epidemic periods of influenza A and B were treated with a combination of Impella® and ECMO. All cases ended in mortality. Dr. Schäfer discusses the characteristics of these patients that led to that outcome and insights gained from these results.

Dr. Schäfer explains that another recent paper demonstrated a reduction in mortality to about 50% with ECMO and Impella in his center. “So, we were really surprised,” he notes, “with this patient cohort we had such a bad outcome.”

Dr. Schäfer emphasizes that what they observed in these patients was new to the cardiologists and virologists alike. Feedback from pathologists on endomyocardial biopsies stated that there was no real myocardial structure left in the biopsy. Dr. Schäfer explains that in acute MI patients they typically try to rescue hibernating or ischemic myocardium. “But if there’s no myocardium left, there’s nothing to rescue and to bridge the patient to.”

Dr. Schäfer also reports that the study led to insights pertaining to the effects of influenza in the heart as well as other organs throughout the body. He notes that in these cardiogenic shock patients, they saw “multiple hits in multiple organs,” and while cardiologists can restore cardiac function, they cannot necessarily restore function to cells in other organs. This, he states, “might be also a potential similarity to what could happen with COVID-19.”

How can this experience inform COVID-19 decision-making? Dr. Schäfer believes that when dealing with a patient who has taken a viral hit to several organs and a ‘bystander hit’ to the heart, that the results for COVID-19 may be pretty similar to what was observed in these patients with influenza. “However, if it’s a COVID-triggered myocardial infarction,” Dr. Schäfer explains, “then I would think it’s rather similar to what we observed in AMI-related cardiogenic shock and completely different from what we reported with the influenza paper.”

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