Percutaneous debulking of tricuspid valve endocarditis in severe COVID-19 pneumonia after prolonged venovenous extracorporeal membrane oxygenation with right-ventricular support: a case series

Background

Over the past 2 years, the utilization of venovenous extracorporeal membrane oxygenation (VV-ECMO) for the treatment of coronavirus disease 2019 (COVID-19) acute respiratory distress syndrome (ARDS) has increased. While supporting respiratory function, VV-ECMO requires large-bore indwelling venous cannulas, which risk bleeding and infections, including endocarditis.

Case summary

We describe two adults hospitalized for COVID-19 pneumonia who developed ARDS and right-ventricular failure, requiring VV-ECMO and ProtekDuo cannulation. After over 100 days with these devices, both patients developed tricuspid valve vegetations. Our first patient was decannulated from ECMO and discharged, but re-presented with a segmental pulmonary embolism and tricuspid mass. The Inari FlowTriver system was chosen to percutaneously remove both the tricuspid mass and pulmonary thromboembolism. Pathological examination of the mass demonstrated Candida albicans endocarditis in the setting of Candida fungemia. Our second patient developed a tricuspid valve vegetation which was also removed with the FlowTriever system. Pathological examination demonstrated endocarditis consistent with Pseudomonas aeruginosa in the setting of Pseudomonas bacteremia. Both patients experienced resolution of fungemia and bacteremia after percutaneous vegetation removal. After ECMO decannulation and percutaneous debulking, both patients experienced prolonged hospital stays for ventilator weaning and were eventually discharged with supplemental oxygen.

Discussion

VV-ECMO and right-ventricular support devices are invasive and create various risks, including bloodstream infection and infective endocarditis. Percutaneous debulking of valvular vegetations associated with these right-sided indwelling devices may be an effective means of infection source control. It is unclear whether prolonged use of VV-ECMO provides a mortality benefit in COVID-19 ARDS.

Mortality and prognostic factors in hospitalized COVID-19 patients with cancer: an analysis from a large healthcare system in the United States

Background

To evaluate clinical outcomes in patients with malignancy who are SARS-CoV-2 (COVID-19) positive and investigate if factors such as age, gender, and race contribute to COVID-19 mortality in patients with malignancy.

Methods

Retrospective data was gathered from Memorial Healthcare System of COVID-19 patients hospitalized from March 1, 2020 to January 18, 2021. Active malignancy was defined as either receiving antineoplastic therapy or being under surveillance. The primary endpoint was in-hospital mortality. Descriptive statistics were used to summarize the characteristics and outcomes. Univariate and multivariate logistic analysis were performed to define baseline clinical characteristics potentially associated with mortality in cancer patients with COVID-19.

Results

A total of 4,870 COVID-19 patients were enrolled in the study, and 265 of those patients had a diagnosis of active malignancy. The study population was diverse which included non-Hispanic whites (NHW) 816 (16.8%), Hispanics 2,271 (46.6%) and Blacks 1,534 (31.5%). Of the cancer patients, 24.1% were NHW, 43% were Hispanic and 28.7% were Black. Amongst the races, 37.5% of in-hospital mortalities were NHW, while 18.4% were Hispanics and 19.7% were Black. The in-hospital mortalities amongst the two malignancy types, solid and hematological, accounted for 24.6% and 23.5% of deaths and they were not found to be statistically significant (P=0.845). After adjustments for age, gender and race were made, cancer was independently associated with an increased in-hospital mortality, with an adjusted odds ratio of 1.48 [95% confidence interval (CI): 1.08-2.01]. Increased age and elevated serum levels of creatinine and C-reactive protein (CRP) were associated with an increased risk of death in cancer patients with COVID-19.

Conclusions

COVID-19 in patients with cancer had poorer outcomes in comparison to those who were cancer-free. Both hematological and solid malignancies had similar in-hospital mortality rates. The highest in-hospital mortalities of cancer patients with COVID-19 were non-Hispanic whites in-comparison to Hispanics with the least. Age, elevated levels of creatinine and CRP were independently associated with increased risk of death in cancer patients hospitalized with COVID-19. The findings indicate the need for close surveillance and monitoring of these patients as they are more likely to have higher risk of death from COVID-19.

Hemoglobinopathies and COVID-19: The Experience of a Center in Northern Greece

Healthcare systems around the globe are still facing the evolving threat of the coronavavirus-19 (COVID-19) pandemic. Hemoglobinopathies include a group of genetic disorders, with the two main entities being thalassemias and sickle cell disease. Due to their immunocompromised status, such patients have been protected as extremely vulnerable to COVID-19 infection. We studied patients with different hemoglobinopathies, consecutively monitored at our center, who were infected with severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) during the second and third waves of the pandemic in Greece (September 2020-April 2021), and associated the outcomes of the infection with the following factors: age, employment, blood type, liver and heart hemosiderosis, splenectomy, concomitant endocrine disorders and transfusion dependency. Among 250 patients monitored at our center, 14 were infected with COVID-19. Nine of them were hospitalized but no one required intensive care unit support and all of them responded to the generally applied treatment plan, despite their comorbidities. Notwithstanding the slightly increased prevalence of COVID-19 in patients with hemoglobinopathies compared to the general population, self-applied measures are still thought to be effective, as our patients got infected through their already sick family members.

Systematic Review and Meta-Analyses of The Interaction Between HIV Infection And COVID-19: Two Years' Evidence Summary

Introduction

During the COVID-19 pandemic, people living with HIV (PLWH) were considered to be at risk of worse COVID-19 outcomes once infected. However, the existing evidence is inconsistent. This systematic review and meta-analysis aimed to compare the risk of SARS-CoV-2 infection, severe COVID-19 symptoms, and mortality among PLWH and patients without HIV.

Method

The articles included studies published in PubMed, Medline, Embase, and Cochrane between December 1, 2019, and December 1, 2021. We included the original studies published in English focusing on observational studies assessing the risk of SARS-CoV-2 infection, severe COVID-19 symptoms, and mortality among PLWH. Four independent reviewers extracted data. STrengthening the Reporting of OBservational studies in Epidemiology-Modified (STROBE-M) checklist was used for quality assessment. For the results with heterogeneity I2 >75%, a random-effects model was employed. Otherwise, a fixed-effects model was used. The risk of SARS-CoV-2 infection, severe COVID-19 symptoms, and mortality were compared with and without HIV.

Results

We included a total of 32 studies and 71,779,737 study samples, of whom 797,564 (1.11%) were PLWH. Compared with COVID-19 patients without HIV infection, PLWH had comparable risk of SARS-CoV-2 infection (adjusted Risk Ratio=1.07, 95% CI: 0.53-2.16, I2 = 96%, study n=6, n=20,199,805) and risk of developing severe COVID-19 symptoms (aRR=1.06, 95% CI: 0.97-1.16, I2 = 75%, n=10, n=2,243,370). PLWH, if infected with SARS-CoV-2, were found to have an increased risk of mortality compared with people without HIV (aRR=1.30, 95% CI: 1.09-1.56, I2 = 76%, study n=16, n=71,032,659). This finding was consistent across different subgroup analyses.

Conclusion

PLWH are at increased risk of COVID-19 related mortality once infected. The local health system should, on the one hand, strengthen COVID-19 prevention and clinical management among PLWH to avoid infection and, on the other hand, sustain the HIV care continuum for PLWH for HIV management.

Association between Hb A1c and Severity of COVID-19 Patients

This study aimed to examine the relationship between Hb A_1c levels and the clinical course of coronavirus-19 (COVID-19) patients. Sixty-six COVID-19(+) patients with high Hb A_1c and 46 with average Hb A_1c and 30 COVID-19(-) patients with average Hb A_1c were included. Hb A_1c levels and parameters examined in COVID-19(+) patients were compared between groups, and correlation analysis was performed between these parameters and Hb A_1c levels. The effect of Hb A_1c levels on intensive care unit (ICU) admission and mortality rate in COVID-19 patients was analyzed with the χ² test. It was observed that hemoglobin (Hb) and arterial oxygen saturation (SaO₂) levels of the COVID-19 (+) groups was lower than the COVID-19 (-) group, while ferritin, D-dimer, procalcitonin (PCT), and C-reactive protein (CRP) levels were higher. The COVID-19 (+) group with high Hb A_1c had higher lactate dehydrogenase (LDH), PCT and D-dimer levels than the other two groups, while Hb, partial arterial oxygen pressure (PaO₂) levels were lower. The Hb A_1c levels of the COVID-19 (+) groups were positively correlated with absolute neutrophil count (ANC), LDH, PCT and (K⁺) levels, while negatively correlated with Hb and PaO₂ levels. Hb A_1c was found to be associated with the inflammation process, coagulation disorders and low PaO₂ in COVID-19 patients. The COVID-19 patients with high Hb A_1c levels had a higher mortality rate than other COVID-19 patients. Using Hb A_1c measurements with other prognostic markers would contribute to the patient's risk of death assessment.