Clare Carr thought her COVID-19 infection was going to be mild. But then it sent her to the intensive care unit and baffled her doctors.
This sun salutation wasn't quite as smooth as most in Clare Carr's daily practice. But after weeks of seeing her in the hospital instead of on her mat, Carr's loved ones watching knew this Facebook stream was the most beautiful yoga video they'd ever seen.
The 32-year-old yoga instructor still can't practice with others while continuing to self-isolate after her COVID-19 infection, but Carr is slowly returning to activities she loves after the novel coronavirus triggered a heart inflammation that put her on life support. For now, her dog Luna is her only yoga student while she remains quarantined for a bit longer at her mom's house.
Novel even for a novel virus
Carr knew she had COVID-19 when she experienced mild symptoms and then got a positive test result, though she'd been social distancing and being as careful as she could. But staying home to wait it out was no longer an option when that seemingly minor case of COVID-19 turned into heart failure – and four episodes of cardiac arrest.
In almost all cases, the chest x-ray is the novel coronavirus tell. Carr's cardiac surgeon, Ashraf Abou El Ela, M.D., describes COVID-19 x-rays from his sickest patients as a "fluffy white-out" of the lung fields.
"But Clare's looked almost normal," says Abou El Ela, of the Michigan Medicine Frankel Cardiovascular Center. "And she had very mild respiratory symptoms, just a slight cough."
It was Carr's heart that was making her so sick, not necessarily the regular symptoms of COVID-19.
"She was outside of all the things we'd been training for, ramping up, learning," nurse practitioner Courtney Clark says. "I'll never forget looking at her chest x-ray. It was pristine compared to the others and you're like, 'What?!'"
They think the virus triggered myopericarditis, which is an inflammation of the heart and surrounding sac, Abou El Ela explains.
He'd only been able to find one similar case report of someone with what's being described as COVID myopericarditis requiring ECMO, so Abou El Ela knew that creativity and ingenuity from a team of experts across Michigan Medicine would be key to figuring out how to get Carr back to the full, active life she'd been thriving in.
A quick decline
"When I was first diagnosed with COVID-19 I felt fine for a couple of days, and then I started getting chest pain and brain fog," Carr remembers.
She went to a local emergency department in late April when she was passing out at home and the chest pain became very severe. Carr was flown to Michigan Medicine after tests showed her heart wasn't able to efficiently pump enough blood to the rest of her body.
"Normally, this function is more than 75%, but Clare's was 10 to 15% at the emergency department," Abou El Ela says. "Apart from COVID-19, she had no medical history that would explain it."
The team tried a few options with medication and catheter-based procedures to get her blood pressure back up, but during all of this, Carr went into cardiac arrest three different times (they'd determined cardiac arrest was also the culprit of her first episode at home). Abou El Ela wasn't going to wait any longer to get her on an advanced form of life support called ECMO that only some hospitals offer.
We were trying to do anything for her. We were throwing all the weapons we had at this disease.Ashraf Abou El Ela, M.D.
Short for extracorporeal membrane oxygenation, ECMO takes over for the patient's heart and lungs to give them more time to recover, like a miniature heart-lung machine. It requires a highly skilled team and comes with risks, but providers are seeing ECMO to be a promising last-ditch effort for those patients who were young and relatively healthy before contracting COVID-19.
Although it was becoming clear that the medical team would have to focus on improving Carr's heart function, her COVID-19 tests were still positive, getting in the way of the regular treatment route.
In most cases, when someone is on ECMO because of sudden drop in heart function, there has to be an exit strategy: waiting for a heart transplant, having a surgery to implant a device that will keep the heart pumping and let the patient leave the hospital, or simply buying time to see if the heart will be able to recover. For Carr, option three was the only one until she had a negative COVID-19 result.
"Our hands were tied," Abou El Ela explains. "When you're on ECMO, the clock starts ticking because our blood is not designed to go in plastic tubing. However, we can't offer heart transplant or a left ventricular assist device (LVAD) to those patients with an active COVID-19 infection, because open heart surgery and immunosuppression can worsen the situation."
Carr's heart was not recovering. So Abou El Ela's team explored every route that might keep Carr alive without open heart surgery, knowing she might not be able to stay on ECMO long enough to become COVID-negative.
"We were trying to do anything for her," he says. "We were throwing all the weapons we had at this disease."
And despite the heart-wrenching situation, Carr's family couldn't visit her in person in order to protect themselves from becoming infected with COVID-19.
"Being that sick for that long without family around can be very difficult," Abou El Ela says, so he called and FaceTimed with Carr's mom and sisters from her hospital room to keep them updated on her condition and the options they were looking into to help her.
Abou El Ela and colleagues decided to give Carr convalescent plasma from someone who has already recovered from COVID-19. No treatments have been proven to stop the novel coronavirus, but convalescent plasma has been used in other diseases before.
Carr was able to come off of ECMO two days later.
"We don't really know if it was the plasma that helped me get better, or the fact that I was a healthy person before all of this, just time, or a combination of all three," Carr says.
A quick rebound
"It was so nice to see her get off ECMO and then get off the breathing machine a day or two later," Clark remembers. The whole unit had become invested in making sure Carr would become a success story. "She was getting too well for our unit and we all saw it coming. The day we transferred her was probably the most emotional day I had at work."
Michigan Medicine team members wheel a victorious Clare Carr out of the ICU after she survived four cardiac arrests triggered by COVID-19 infection. Video courtesy of Carr.
After more recovery time and starting physical therapy out of the intensive care unit, Carr was able to go home a week ago. Now, the focus is on the lengthy recovery ahead.
She's working on regaining her strength, slowly getting back into her regular yoga and exercise practice and trying to stay positive through it all.
"I'm going through some post-traumatic stress," Carr says. "It's hard not to focus on the negative, but I'm learning how to accept that this happened to me and figure out the new normal. I keep reminding myself that I've come so far and I'm alive."
"My family and I are very grateful for the wonderful team of doctors, surgeons, nurses and everyone who provided the most exceptional care and went above and beyond. We are so blessed," Carr says.
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