Exploring Personal Protection During High-Risk PCI in a COVID-19 Patient: Impella CP Mechanical Support During ULMCA Bifurcation Stenting.

The correct management of patients with coronavirus disease-2019 (COVID-19) and acute coronary syndrome is still uncertain. We describe the percutaneous treatment of an unprotected left main coronary artery in a patient who is positive for COVID-19 with unstable angina, dyspnea and fever. Particular attention will be dedicated to the measures adopted in the catheterization laboratory to protect the staff and to avoid further spread of the infection. (Level of Difficulty: Intermediate.).

History of Presentation

A 70-year-old gentleman with unstable angina was transferred to our center with persistent chest pain despite maximum antianginals. On admission, his blood pressure was 100/65 mm Hg, heart rate 72 beats/min and respiratory rate 14 breaths/min. Physical examination revealed normal vital signs, regular heart rhythm with no significant murmurs, and some bibasilar lung rales.

Learning Objectives

Cardiovascular diseases significantly increase mortality in infected patients.

Heart team discussion is key in decision making in this subset of patient.

Personal protection protocols are fundamental to reduce the risk of infection in health care workers.

He was referred to our hospital after presenting to a hospital in Bergamo and having angiographic evidence of chronic total occlusion of the right coronary artery (Video 1) and critical stenosis of distal left main coronary artery (LMCA) involving the ostia of both left anterior descending and left circumflex arteries (Videos 2 and 3). After the diagnostic angiogram, he was started on aspirin 100 mg and atorvastatin 80 mg once a day. From his blood tests, initial high-sensitivity troponin I was 11 ng/l (normal range <34 ng/l) and B-type natriuretic peptide was 719 pg/ml (normal range <300 pg/ml).

Online Video 1

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Diagnostic Coronary Angiography: LAO View of RCA CTO

Diagnostic coronary angiography: left anterior oblique (LAO) view of right coronary artery (RCA) chronic total occlusion (CTO).

Diagnostic Coronary Angiography: RAO Caudal View of Critical LMCA Stenosis

Diagnostic coronary angiography: right anterior oblique (RAO) caudal view of critical left main coronary artery (LMCA) stenosis.

Diagnostic Coronary Angiography: CRA View of Critical LMCA Stenosis

Diagnostic coronary angiography: cranial (CRA) view of critical left main coronary artery (LMCA) stenosis.

The patient had an electrocardiogram (Figure 1) that demonstrated sinus rhythm, left anterior fascicular block, and left axis deviation. A bedside echocardiogram on admission demonstrated a left ventricular ejection fraction of 45% with left anterior descending territory severe hypokinesis.

Figure 1

Electrocardiogram

Past Medical History

Aside from previous bladder cancer, the patient denied any past cardiac events or cardiac risk factors. He was not on any medication prior to the diagnostic angiogram.

Management

After the heart team’s discussion, it was decided to refer the patient to surgical revascularization within the 2 following days. However, after a few hours, the patient developed cough and fever (>39°C). Urgent chest x-rays demonstrated interstitial involvement of the lungs, which is suggestive for severe acute respiratory syndrome coronavirus 2 infection (Figure 2). The diagnosis of coronavirus disease-2019 (COVID-19) was then confirmed by the reverse transcriptase polymerase chain reaction test, and so the patient was transferred to a negative pressure airflow room. In the next days, due to the recurrence of chest pain and hyperthermia, accompanied by thrombocytopenia, leukopenia, and mild hypoxia, we decided to have a second, urgent heart team discussion after the evaluation by the infectious disease specialist and the intensivist. Based on the hypothesis that the patient’s respiratory function may deteriorate further, it was decided to treat the coronary disease percutaneously to avoid surgical-related morbidity, going beyond current practice guidelines (1).

Figure 2

Chest Radiograph Showing Interstitial Bilateral Infiltrations

In the light of the complex coronary artery disease, given the left ventricular dysfunction and the intention to perform LMCA stenting with a double-stent bifurcation technique in the presence of a chronic total occlusion of the right coronary artery, it was given indication to use a temporary left ventricular support device: the Impella CP system (Abiomed, Inc., Danvers, Massachusetts). (Disclaimer: The use of Impella described in this case is not currently approved in the United States.)

The LMCA was treated using the double kissing–crush technique, with excellent angiographic result confirmed by intravascular ultrasounds (Figures 3 and 4, Video 4). The double kissing–crush technique has been widely described elsewhere (2).

Figure 3

Distal LMCA Critical Stenosis

Coronary angiography showing distal left main coronary artery (LMCA) critical stenosis. (A) Right caudal view; (B) cranial view.

Figure 4

Result of ULMCA PCI With Impella CP Support

Coronary angiography showing the result of upper left main coronary artery (ULMCA) percutaneous coronary intervention (PCI) with Impella CP support. (A) Caudal view; (B) cranial view.

Online Video 4

Coronary Angiography: CAU View of Final Result of LMCA DK-Crush Stenting

Coronary angiography: caudal (CAU) view of final result of left main coronary artery (LMCA) double kissing (DK)-crush stenting.

After the procedure, the Impella CP catheter was removed without complications, and the femoral access was closed with the use of 2 Proglide closure systems (Abbott Vascular, Santa Clara, California).

Protective Equipment in the Catheterization Lab

The staff allowed to enter the catheterization lab consisted of 2 cardiologists as first and second operator, 2 nurses, and an x-ray technician. The catheterization lab could not be negative pressure as we could not change the settings. However, after discussing the risks and benefits of proceeding, we accepted the risk of the positive flow.

The patient entered the operating room with a surgical mask, whereas all the operators were wearing a Filtering Facepiece 3 (FF3) mask along with facial shield, a sterile surgical gown, leg covers, and 2 pairs of surgical gloves per World Health Organization protocol (3).

The procedure of wearing and removing these devices was proposed by the European Center of Disease Protection and Control (4).

At the end of the procedure, all the used disposable material was treated separately to avoid any possible contamination.

Subsequent Hospital Care and Follow-up

During the post-operative stay, the patient had no other episodes of chest pain, and his vital parameters remained stable. The patient had another echocardiogram that demonstrated that his ejection fraction increased to 55% and regional wall motion abnormalities resolved (Videos 5 and 6). Given the previous treatment with aspirin 100 mg daily, at the time of the procedure, 2 crushed 90-mg pills (180 mg) of ticagrelor (5,6) were administered to put the patient in dual antiplatelet therapy. Regarding COVID-19, despite the continuous high fever and dry cough, the patient’s respiratory parameters remained stable. Medical treatment consisted of antipyretic treatment (1 g of paracetamol intravenous) and antibiotic prophylaxis with vancomycin 2 g/24 h intravenous and piperacillin/tazobactam 4.5 g every 8 h to avoid possible bacterial superinfections. Up to now, the patient has shown an improvement of his clinical conditions with no more need for oxygen supplementation. There has been no fever in the last 5 days despite the persistence of dry cough. The patient has been mobilized but is still isolated due to COVID-19 management protocol.

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Transthoracic Echocardiogram: Parasternal Long-Axis View

Transthoracic echocardiogram: parasternal long-axis view showing normal left ventricular systolic function.

Transthoracic Echocardiogram: Apical 4-Chamber View

Discussion

Since its outbreak in Italy in mid-February, COVID-19 has spread rapidly, with over 40,000 cases and more than 3,000 deaths to date. Epidemiologic analysis shows that the presence of comorbidities significantly increases mortality: 10.5% in patients with cardiovascular diseases; 7.3% in patients with diabetics; 6.3% in patients with chronic respiratory diseases; 6% in patients with hypertension; and 5.6% in oncologic patients (7). Given the high number of infected patients, we often diagnose cardiovascular diseases at different stages during the viral pathology. In this perspective, some selected patients could benefit from treatments that deviate from current guidelines.

We report the first case of a patient with COVID-19 and acute coronary syndromes treated in Italy for unprotected LMCA stenosis with protected percutaneous coronary intervention. The use of the Impella CP cardiac assist system to provide left ventricular support during high-risk percutaneous coronary interventions is recommended in such settings, because its efficacy is supported by randomized-controlled trials (8) and large registries (9,10). Nevertheless, this case also highlights the importance of personal protection protocols to reduce the risk of infection during a spreading pandemic. The American College of Cardiology very recently published a position paper on catheterization considerations in patients positive for COVID-19. Our patient was treated almost a month prior to the release of these guidelines (11).

As of now, the Italian Ministry of Health reports 2,629 cases of COVID-19 among health care workers (8.3% of all active cases). These data confirm that the correct application of safety protocols is of utmost importance while dealing with this exploding emergency. Although we understand that few hospitals in China may have administered thrombolysis, we did not consider this option as we employ thrombolysis if time to percutaneous intervention exceeds 120 min.

Conclusions

COVID-19 cases are rapidly growing and cardiovascular diseases significantly increase their mortality. To our knowledge, our case is the first to report a patient with COVID-19 with associated acute coronary syndromes and hemodynamic instability requiring urgent treatment.

The rapid growth of the COVID-19 dictates the adoption of complex personal protection protocols to avoid infection in health care operators.