The novel coronavirus outbreak first occurred in Wuhan, Chine in December 2019 and spread rapidly to all over the world. The health providing systems have changed and focused on COVID-19 disease since the first case was declared at March 11, 2020 in Turkey, like have been in almost all countries. In general meaning, this case presentation could be seen as it didn’t has any novel treatment strategies or any technical attributes. But in our knowledge, LVAD implantation in novel coronavirus pandemic period was not declared in any clinic and thus, it seems LVAD implantations to the patients whether COVID positive or not, were postponed at most of clinics. In our clinic after first case was declared at March 11 in Turkey, our approaches to the patients who were planned to LVAD implantation were mostly favor to postpone. However, with the advancing time, our thought turned to that this group of patients may be more risky in this uncertain process. In normal periods, most of physicians who interested in heart failure treatments recommend that implantation of LVAD to the patients in the INTERMACS 4 or 5 levels, rather than to the same patients after worsening to the lower INTERMACS levels (4,5). The implantation strategies to the children were substantially diﬀerent previously than adult with same conditions. However, lately the strategies turned to similar with adults due to the development of relatively smaller sized devices (6). In fact, if our present case who was an 11-year-old girl with heart failure related to myocarditis would have happened in normal period, we could plan to implant a LVAD earlier, but due to confusion of this unfamiliar pandemic period we could not achieve consensus between the clinics of cardiovascular surgery, pediatric cardiology and anesthesiology. Eventually we decided to extend the medical treatment process as much as possible and avoid surgical procedures.
Even, our hospital was not yet accepted as a pandemic hospital. In literature some controversial thoughts have been present and published about intravenous immunoglobulin (IVIG) therapy (7,8). As it was mentioned above our initial approach was to continue with medical therapy which included IVIG during the patient was stable with IV diuretic and low dose inotrope. But we could not get a benefit from this therapy.
In general public health practices, due to the virus spreading rapidly in pandemic situations, most of cases except those requiring urgency are postponed with prediction of overwhelming and lack of bed in hospitals (9). It is also known that surgical and medical treatments for chronic heart failure do not exist among cardiac emergencies which can be assumed as exceptional condition (10). However, it is also stated that patients with chronic heart failure can frequently apply to emergency departments, despite maximal medical treatment, and very few are sent back to home (11). Considering the burden of hospitals during pandemic periods, attempts to reduce the frequency of hospital admissions of these patients can be considered not only for individual health but also for public health. In the present case, initially we didn't meet this thought, and we were of the opinion that extending the duration of medical treatment to as long as could been would have been the best option. But, the condition of our patient rapidly decreased from INTERMACS 4 to INTERMACS 2, and the healing process after LVAD implantation has not yet been satisfactory, similar with the comparative studies (5).
There are limited publications on elective surgical procedures during the coronavirus pandemic period. In the study of Lei et al., mortality rates of surgeries applied to patients in the incubation period were noticeably high. This rate was seen to be much higher, especially in the high-risk patient group (12). Left ventricular assist device implantations that if were considered as high-risk surgery, even these patients have been operated at the incubation period, would be at high risk. The cultures which were taken from our patient 2 times consecutively were resulted negative, and there were no radiological findings suggesting COVID-19 disease. But, the lack of experience in both our clinic and the literature restricted us to choose the most appropriate approach related to such processes.
It is known that individuals with any chronic disease constituted the most risky population during the coronavirus pandemic period (2). As with all patients with chronic diseases such as cancer, any implementations that are applied in order to minimize the admission to hospital and even remote monitoring of patients gain importance (13). Furthermore, the preference of the applications that will shorten the hospitalization period during surgical intervention may also be useful (14). On the other hand, self - measurement of International Normalized Ratio (INR) which has been the most frequently followed laboratory parameter in LVAD patients, could also contribute to reducing hospital admissions (15).
In conclusion, performing LVAD implantation to the patients in INTERMACS 4 or 5 as soon as possible may be a more eﬀective approach, rather than delaying, in coronavirus pandemic process, in which we do not have enough information about the process yet. We believe that this case report may also give insight into comparative studies that will enable us to make more accurate decisions.