Cardiovascular Journal of Africa: Vol 32 No 6 (NOVEMBER/DECEMBER 2021)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 6, November/December 2021 AFRICA 345 be considered. The patient received 500 mg methylprednisolone pulse treatment for three days, which was effective, along with complicated treatment involving immunosuppression, anti- infection therapy, continuous renal-replacement therapy and nutritional support. ECMO was successfully weaned off on postoperative day five. COVID-19 viral testing of sputum or broncho-alveolar lavage fluid (when possible) and stool was conducted every postoperative day and remained negative. The patient gradually became well with aggressive follow-up treatment and rehabilitation training and currently remains well. Discussion Lung transplantation, as a final option, was an urgently needed salvage therapy for the patient described in our case to prevent certain death because of severe respiratory failure without any signs of respiratory improvement with maximal medical support after consecutive negative COVID-19 nucleic acid tests. The confirmation of irreversible refractory failure and the absence of other organ system dysfunction led to the treatment decision of lung transplantation, which was arranged in accordance with the national organ allocation principles, 3 with the priority of urgency related to disease severity. Impairment of the heart caused by COVID-19 was not clear to us during the first few months of the pandemic. Precise evaluation of cardiac function using peri-operative echocardiography was requisite in clinical decision making for this lung transplantation patient, especially considering the status of haemodynamic instability. Before the operation, the gradual increase of PASP and the decrease of TAPSE suggested aggravation of the lung lesions and tolerance to sustained pressure overload, which assisted in the clinical strategy in the absence of Swan–Ganz catheterisation owing to the poor condition of the vessels, which was probably related to the high body mass index of 31 kg/m 2 . After lung reperfusion, conversion to VA-ECMO was applied to facilitate offloading of the right heart during persistent RV dysfunction without anastomotic stenosis, as diagnosed by TEE. TEE was performed again because of an obscure image on initial TTE attributed to postoperative gas interference from a clamshell incision from the lung transplantation. The elevation of PASP, up to nearly 62 mmHg, likely indicated pulmonary small-vessel contraction, which may be attributed to hypoxaemia owing to allograft rejection with concomitant perivascular inflammation and airway inflammation. 4 Furthermore, the thickening of the RV wall may have been a sign of myocardial oedema due to lung rejection, as it was normal before the operation. Inciardi et al . reported a COVID-19 patient with cardiac involvement who presented with increased wall thickness and diffuse biventricular hypokinesis confirmed by cardiac magnetic resonance imaging. 5 We speculated that the probability of cardiac impairment caused by COVID-19 in the postoperative period would be very low, as the airway secretion and stool samples all tested negative for COVID-19 after the operation. Under protective clothing, the performance of beside echocardiography requires a longer time and consumes more ICU resources, but it is necessary to ensure self-protection. We placed the ultrasonic machine on the left side of the bed and stood at the bedside with our backs to the patient and held the probe in our right hand to perform TTE for patients in the ICU. This is considered to be a good method for avoiding infection while in close contact with patients but requires personnel who are highly experienced in performing echocardiography. For TEE, a disposable protective cover was used for the probe as usual. A headcover with positive pressure was not used owing to the relatively short time of TEE examination in the operating room. Additionally, echocardiographers should be familiar with the mechanism and complications of ECMO, because it provides indispensable assistance for haemodynamic instability. 6 The left heart systolic function needs to be closely monitored by echocardiography owing to the increased afterload produced by VA-ECMO support. Conclusion Peri-operative echocardiography played an important role in the management of an obese patient with lung transplantation because of severe respiratory failure caused by COVID-19. Echocardiographers should be familiar with the complications of lung transplantation and the haemodynamics under ECMO support to achieve a more accurate interpretation of cardiac parameters. This work was supported by the Health and Family Planning Commission of Zhejiang Province (No. 2018KY070). References 1. 1. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention. J Am Med Assoc 2020 Feb 24. Online ahead of print. 2. 2. Meyer KC. Recent advances in lung transplantation. F1000Res 2018 Oct 23. Online ahead of print. 3. 3. Huang J. The ‘Chinese Mode’ of organ donation and transplantation. Hepatobiliary Surg Nutr 2017; 6 (4): 212–214. 4. 4. Benzimra M, Calligaro GL, Glanville AR. Acute rejection. J Thorac Dis 2017; 9 (12): 5440–5457. 5. 5. Inciardi RM, Lupi L, Zaccone G, et al . Cardiac involvement in a patient with coronavirus disease 2019 (COVID-19). J Am Med Assoc Cardiol 2020 Mar 27. Online ahead of print. 6. 6. FoongTW, RamanathanK, ChanKKM,MacLarenG. Extracorporeal membrane oxygenation during adult noncardiac surgery and periopera- tive emergencies: a narrative review. J Cardiothorac Vasc Anesth 2020 Jan 21. Online ahead of print.