A Severe COVID-19 Case Complicated by Right Atrium Thrombus

Spectrum of Thrombotic Complications in Fatal Cases of COVID-19: Focus on Pulmonary Artery Thrombosis In Situ

COVID-19-related thrombosis affects the venous and arterial systems. Data from 156 autopsies of COVID-19 patients were retrospectively analyzed to investigate the pattern of thrombotic complications and factors associated with pulmonary artery thrombosis and thromboembolism. Thrombotic complications were observed in a significant proportion (n = 68, 44%), with pulmonary artery thrombosis the most frequently identified thrombotic event (42, 27%). Multivariate analysis revealed that the length of hospital stay (OR 1.1, p = 0.004), neutrophil infiltration in the alveolar spaces (OR 3.6, p = 0.002), and the absence of hyaline membranes (OR 0.1, p = 0.01) were associated with thrombotic complications. Neutrophil infiltration in the alveolar spaces (OR 8, p < 0.001) and the absence of hyaline membranes (OR 0.1, p = 0.003) were also independent predictors of pulmonary artery thrombosis. The association of pulmonary artery thrombosis with an absence of hyaline membranes suggests it occurs later in the course of COVID-19 infection. As neutrophil infiltration in the alveolar spaces may indicate bacterial infection, our studies suggest the consideration of bacterial infections in these critically ill patients.

Acute thrombotic occlusion involving three coronary arteries. A unique association with COVID-19 pneumonia

Key Clinical Message

Respiratory viruses, particularly COVID-19, can be associated with severe cases of myocardial infarction (MI). Physicians should have a low threshold for MI in COVID-19 patients who present with persistent chest pain as MI in rapidly deteriorating cases can be missed. Prompt response includes both timely diagnosis and swift treatment.

Abstract

The coronavirus disease 2019 (COVID-19) is associated with coronary artery thrombosis. Many cases of single-vessel and few cases of two-vessel thrombosis were reported. Herein, we report a unique association in a middle-aged man diagnosed with COVID-19 and presented later with acute myocardial infarction causing cardiogenic shock. The patient was found to have three-vessel thrombosis.

Impact of Alteplase on Mortality in Critically Ill Patients with COVID-19 and Pulmonary Embolism

COVID-19 is an independent risk factor for pulmonary embolism (PE). Little is known about alteplase therapy in this patient group. A retrospective study analyzed 74 patients with PE and acute respiratory distress syndrome (ARDS) due to COVID-19 who were hospitalized in the intensive care unit in 2021. Patients with or without confirmed right heart thrombi (RHT) were treated with unfractionated heparin or alteplase. The mortality rate in patients with RHT treated with heparin was 100% compared to 37.9% and 55.2% in those treated with alteplase without RHT and alteplase with RHT, respectively. The risk of death in the alteplase group increased with delayed thrombolysis (p = 0.009, odds ratio (OR) = 1.73 95% CI (confidence interval) 1.14-2.62), increased D-dimer concentration (p = 0.02, OR = 1.43 95% CI 1.06-1.93), and decreased PaO₂/FiO₂ ratio (p = 0.001, OR = 0.56 95% CI 0.41-0.78). The receiver operating characteristic method determined that a 1-day delay in thrombolytic treatment, D-dimer concentration >5.844 mg/L, and PaO₂/FiO₂ <144 mmHg predicted a fatal outcome. The risk of death in patients with severe COVID-19 with ARDS and PE increases with higher D-dimer levels, decreased PaO₂/FiO₂, and delayed thrombolytic treatment. Thrombolysis seems to be treatment of choice in severe COVID-19 with PE and RHT. It should be carried out as soon as possible after the diagnosis is established.

Right Atrial Thrombus and Submassive Pulmonary Embolism in a COVID-19-Infected Patient: A Case Report

Coronavirus disease 2019 (COVID-19) is primarily a respiratory infection, but it undoubtedly results in systemic illness that affects multiple systems. The high incidence of thromboembolic events is one distinctive clinical characteristic of COVID-19. This case report is about a unique clinical presentation of a 40-year-old homeless female with polysubstance abuse, who was diagnosed with a right atrial thrombus, sub-massive pulmonary embolism, and COVID-19 infection. The patient presented with shortness of breath, subjective fevers, generalized swelling, and chest and upper abdominal pain. Initially, she was treated with tissue plasminogen activator (TPA) and heparin drip for her thrombi, and she was managed conservatively when hemoptysis ensued post-TPA. She was later sent to a higher level of care for surgical embolectomy. In most cases, severe pulmonary parenchymal disease secondary to COVID-19 correlates with the severity of thromboembolic complications, however, in our case report, there was a right atrial thrombus and pulmonary embolism in the absence of COVID pneumonia. This highlights how notorious COVID-19 infections can be.

Low dose ultra-slow infusion thrombolytic therapy (LDUSITT) as an alternative option in a COVID-19 patient with free-floating right atrial thrombus: a case report and review of literature

The hyper-coagulopathy nature of COVID-19 is a prevalent consequence among patients. Free-floating right atrial thrombi are a relatively rare finding and the optimal therapy is a therapeutic dilemma.We present a 37-year-old woman with acute dyspnea and fatigue. Several ground glass opacities were shown on computed tomography of chest that further proved to be associated with severe COVID-19 disease. A transthoracic echocardiography revealed a mobile right atrial mass with bilateral pulmonary embolism. She was considered high risk for surgical therapy by cardiovascular surgeons. She was then started on anticoagulation therapy for 5 days however the size regression of the thrombus remained unchanged. A regimen of low dose (24 mg) ultra-slow (24 h) intravenous infusion of alteplase, without bolus was initiated. Following the third day of thrombolytic therapy, the control echocardiography demonstrated complete resolution of the thrombus.Prolonged infusion of low dose fibrinolytics can be an alternative treatment to surgery for right heart thrombi.

Right atrial thrombus, junctional tachycardia, and critical lower limb ischemia: three rare complications of severe acute respiratory syndrome coronavirus 2 infection

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can engender multi-system inflammatory syndrome. Its main symptoms are cardiovascular and thromboembolic problems that can develop into severe complications. The present case is about a 55-year-old patient who was admitted for critical ischemia of the right lower limb and necrosis of the right forefoot. The patient was infected with coronavirus disease 2019 (COVID-19) one month before her admission. The patient also has cardiovascular risks including type 2 diabetes and hypertension. The performance of ultrasounds revealed a thrombus in the right atrium and the pulmonary artery, and arteriography detected an occlusion of the right popliteal joint for which she had an endovascular recanalization and amputation of the right forefoot. This case highlights that SARS-CoV-2 infection could be considered a serious cardiovascular disease requiring cardiovascular explorations to initiate hospital management and avoid severe complications.

Pulmonary thromboembolism in conjunction with intracavitary thrombus caused by severe acute respiratory syndrome coronavirus-2 infection in a patient living with human immunodeficiency virus

Approximately one-third of patients with coronavirus disease 2019 (COVID-19) present with coagulation disorders and hematological changes. However, the clinical manifestations of COVID-19 and prognoses of people living with human immunodeficiency virus (HIV) remain controversial. This study reports the case of a 27-year-old HIV-infected man who regularly used antiretroviral medications, had no other comorbidities and was admitted for acute respiratory distress syndrome caused by COVID-19. Complementary examinations during hospitalization revealed a diagnosis of pulmonary thromboembolism in association with an intracavitary thrombus.