Intra cardiac thrombus in critically ill patient with coronavirus disease 2019: Case report

A review of the presentation and outcome of left ventricular thrombus in coronavirus disease 2019 infection

BACKGROUND

Cardiovascular complications of the coronavirus disease 2019 (COVID-19), which is caused by the severe acute respiratory syndrome coronavirus 2 (SARS- CoV-2), have been documented both in the acute phase and in convalescence. One such complication is the formation of the left ventricular (LV) thrombus. There is a lack of clarity regarding the incidence, risk factors, and management of this complication.

AIM

The aim of the study is to identify the clinical presentation, risk factors and outcome of COVID-19 patients with left ventricular thrombus (LVT).

METHODS

A literature search was conducted to identify all case reports of COVID-19 with LVT in PubMed/Medline, Embase, Web of Science, and Google Scholar.

RESULTS

Among the 65 patients identified, 60 had LVT, either at admission, or during the acute phase of the illness. Six patients with mild symptoms during the acute phase of viral illness had only the COVID-19 antibody test positivity at the time LV thrombus was detected. Few of the patients (23.1%) had no comorbidities. The mean age of the patients was 52.8 years, and the youngest patient was 4 years old. This suggests that LVT formation can occur in young COVID-19 patients with no co-morbid conditions. Most of the patients (69.2%) had more than one site of thrombosis. A mortality rate of 23.1% was observed in our review, and ST-elevation myocardial infarction (STEMI) was diagnosed in 33.3% of those who died.

CONCLUSIONS

A high degree of suspicion for LVT must be maintained in patients with known cardiac disease and those with new-onset arterial or venous thromboembolism, and such patients may benefit from a screening echocardiography at admission.

RELEVANCE FOR PATIENTS

The patients with preexisting cardiovascular disease must take added precautions to prevent acquiring COVID-19 infection as there is a higher risk of developing LV thrombus. In patients who develop LVT in COVID-19, mortality rate is higher.

Incidental diagnosis of a large cardiac thrombus swinging through an interatrial communication in a COVID-19 patient: Case report and literature review

Introduction

The hypercoagulability state induced by COVID-19 has been well established and various forms of subsequent thromboembolic events have been reported throughout literature including multiple cases of intracardiac thrombi, four of which in our center alone, this case being the fifth.

Case report

We report the case of a 38-year-old male with no prior cardiovascular history who -subsequently to a COVID-19 infection-developped a right atrial thrombosis associated to a pulmonary embolism, and in whom cardiography revealed an interatrial communication. Management relied upon curative doses of low molecular weight heparin (LMWH) with favourable outcome.

Discussion

In our discussion, we lay out the various physiopathological mechanisms incriminated throughout literature in the genesis of a hypercoagulability state distinctive of COVID-19, before highlighting the incidence of an interatrial communication (whether a Potent Foramen Ovale or Atrial Septal Defect) discovered in patients with COVID-19, and the potential paradoxical embolization risks they imply as well as reported cases. A mention of hemostatic parameters monitored was also warranted. Finally we discuss the guidelines in terms of prophylactic and therapeutic anticoagulation in hospitalized patients before discussing cardiac thrombosis's therapeutic options.

Conclusion

Our case highlights various key points which could change the prognosis of COVID-19 patients, whether related to the underdiagnosis of interatrial abnormalities or with regards to the diagnosis to thromboembolic events, but also the indisputable place of anticoagulation in COVID-19 management.

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Thromboembolic events complicating COVID-19 have been well described and are attributed to a hypercoagulability state distinctive of COVID-19.

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A pre-existing Potent Foramen Ovale (PFO) or Atrial septal Defect (ASD) in COVID-19 patients is unknown as only a handful of studies covered the subject.

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The association of a cardiac thrombosis with a pulmonary embolism and interatrial communication exposes patients to risks of paradoxical embolization and subsequent arterial thrombotic events.

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Prophylactic and curatrive anticoagulation is unrefutably a key pillar in the management of COVID-19.

Early initiation of awake venovenous extracorporeal membrane oxygenation (ECMO) in critical COVID-19 pneumonia: A case reports

Introduction

Overall, patients with Sars-cov-2 disease treated with mechanical ventilation, which is not the case in our study. This report presents our first successful experience of awake ECMO application in a critical patient with hypoxemic Respiratory Failure related to COVID-19 infection in Morocco.

Case management

We have reported a 52-year-old female patient who was diagnosed with COVID-19 infection and progressed to critical cases. She was a candidate for applying awake extracorporeal membrane oxygenation (ECMO) in the absence of invasive mechanical ventilation, under local anesthesia alone with good progress and ventilatory weaning.

Conclusion

This therapeutic attitude can be beneficial for certain critical and severe cases due to COVID-19 infection. Each ECMO program should develop goals, methods, protocols, and best practices while adapting appropriately to the personnel and equipment available.

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Extracorporeal membrane oxygenation (ECMO) is extracorporeal life support used as salvage therapies in patients with acute cardiac, pulmonary or cardiopulmonary failure.

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Early initiation of awake venovenous extracorporeal membrane oxygenation (ECMO) in critical cases of COVID-19 infection.

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“Awake ECMO” support in patients with COVID-19 is feasible and has benefits in the absence of mechanical ventilation.