Case Report: An Unusual Case of Biventricular Thrombosis in a COVID-19 Patient With Ischemic Dilated Cardiomyopathy: Assessment of Mass Mobility and Embolic Risk by Tissue Doppler Imaging

Anesthetic Management of Patients with Dilated Cardiomyopathy Undergoing Noncardiac Surgery

Dilated cardiomyopathy (DCM), a primary myocardial disease, is characterized by dilation of the left or both ventricles and systolic dysfunction with or without congestive heart failure. DCM per se is a well-recognized risk factor for sudden cardiac death and poor surgical outcomes following noncardiac surgery. Surgical trauma/stress represents unique challenges for DCM patient management. Unfortunately, there is a big knowledge gap in managing DCM patients undergoing non-cardiac surgery. Therefore, the aim of our review is to provide basic facts and current advances in DCM, as well as a practical guideline to perioperative care providers, for the management of surgical patients with DCM, who are quite rare compared with the general surgical population. This review summarizes recent advances in the medical management of DCM as well as perioperative assessment and management strategies for DCM patients undergoing noncardiac surgery. Optimal surgical outcomes depend on multiple-disciplinary care to minimize perioperative cardiovascular disturbances.

Features of Myocarditis: Morphological Differential Diagnosis in Post-COVID-19 Children

Myocarditis is characterized by dysfunction and destruction of cardiomyocytes, infiltrative inflammation, and development of fibrosis. Late diagnosis of myocarditis has been a serious global health problem, especially due to the spread of a new coronavirus infection. The aim of this review is to identify differences between myocarditis of viral etiology, including SARS-CoV-2 lesions, based on instrumental and pathomorphological findings.

MATERIAL AND METHODS

We analyzed publications covering the period from December 2019 to May 2023, published in publicly accessible international databases ("Medline", "PubMed", "Scopus"), with queries for the keywords "myocarditis", "children", "cardiovascular inflammation", "COVID-19", "SARS-CoV-2", "severe acute respiratory syndrome coronavirus 2", "differential diagnosis".

RESULTS

It was found that no unambiguous morphological criteria for the diagnosis of myocarditis coupled to SARS-CoV-2 lesions were identified. However, the detected histopathological changes such as virus-associated degeneration, apoptosis, cardiomyocyte necrosis, moderate interstitial hyperemia, myocardial tissue oedema, and capillary endothelial cell dysfunction were the major markers of SARS-CoV-2 infection.

CONCLUSION

It is necessary further reconsider morphological criteria to diagnose SARS-CoV-2-caused myocarditis, rather than solely relying on detecting viral RNA by PCR as the sole evidence-based criterion. Similar issues accompany diagnostics of myocardial lesions associated with other viral infections. Evidence for an etiological diagnosis of myocarditis can be provided by a comprehensive analysis of the diagnostic criteria obtained, confirming virus exposure, followed by development of distinct clinical symptoms, MRI and CT changes, and morphological criteria.

Retrospective Analysis of Left Ventricular Thrombus Among Heart Failure Patients with Reduced Ejection Fraction at a Single Tertiary Care Hospital in Somalia

Introduction

Left ventricular thrombus (LVT) is a common complication in patients with systolic heart failure and can cause thromboembolic consequences including stroke. In order to determine the characteristics of LV thrombus among heart failure patients with reduced ejection fraction (HFrEF), the present study was undertaken.

Methods and Materials

This was retrospective cross-sectional study conducted from referral tertiary hospital in a year period. A total of 810 transthoracic echocardiograms were carried out in our center from January 2021 to December 2021. Forty participants had met the inclusion criteria of the study.

Results

About 75% of the population was male and the mean age at diagnosis was 51 years (SD: 15). Ischemic cardiomyopathy and dilated cardiomyopathy (DCMP) found to be the most underlying cause of LVT represented (57.5% and 42.5% respectively). Hypertension, hypothyroidism, and atrial fibrillation were found to be the commonest associated risk factors of LVT, 45%, 12.5%, and 30% respectively. Simpson's Biplane's approach yielded a mean LVEF of 25.25 ± 6.97. 60% of the patients had a LVEF of ≤25%. The mean LV end-diastolic and end-systolic diameters were 59.2 ± 9.4 mm and 51 ± 8.3mm respectively. Warfarin was administered to 19 (47.5), Rivaroxaban to 8 (20), and Dabigatran to 10 (25). The most prevalent anticoagulant among the individuals in our study was warfarin. A stroke complication was found in 8 patients (20%), two of them were hemorrhagic stroke and they were on dabigatran. A Peripheral Arterial Disease (PAD) affected 6 of the patients (15%). One of those with PAD had also ischemic stroke.

Conclusion

This study determines that Ischemic and Dilated cardiomyopathy were the most common cause of left ventricular thrombosis among HFrEF patients in Somalia.

Anticoagulation for left ventricular thrombi secondary to COVID —Is 3 months too long?

The length of anticoagulation for thrombotic events related to COVID‐19 is unknown. We present a patient with COVID‐19 complicated by a thrombotic anterior STEMI and multiple left ventricular (LV) thrombi that resolved after 8 weeks of anticoagulation. We suggest a shorter length of anticoagulation with COVID‐19‐related LV thrombus.

Cardiac Thromboembolism in COVID-19: A Case Series

Venous thromboembolism (VTE) is a very common complication of coronavirus disease-2019 (COVID-19) because of the acquired hypercoagulability in these patients. Cardiovascular thromboembolism (CTE) is another complication that is relatively rare yet catastrophic. We present two cases of COVID-19 which were complicated by CTE. Case one describes a 55-year-old male with COVID-19 who had an ST-segment elevation myocardial infarction (STEMI) secondary to coronary artery embolism and was also found to have biventricular thrombi (BVT). Case two describes a 65-year-old female presenting with STEMI secondary to coronary artery embolism. This document highlights how CTE can be present in COVID-19 patients and describes the available evidence for its management. Given the paucity of data on these complications, we illustrate the offered treatment which was based on the data extrapolated from the treatment of VTE in COVID-19 and the treatment of CTE in non-COVID-19 patients.

Multiple biventricular thrombi in a patient with alcoholic cardiomyopathy and COVID-19: A tragic association in a deadly pandemic

As a primary cause, intracardiac thrombi are seen in a variety of cardiac conditions such as acute anterior myocardial infarctions and dilated cardiomyopathy. However, there are secondary predisposing conditions that increase the risk of clot formation in normally functioning ventricles. Migration or embolization of thrombus produced elsewhere, such as pulmonary thrombo-embolism, may occur at times. However, the current coronavirus disease 2019 (COVID-19) pandemic has resulted in a variety of intracardiac or extracardiac thrombi formations due to systemic inflammation and activation of the clotting system. We present a unique and rare case in association with alcoholic dilated cardiomyopathy and COVID-19, which resulted in the development of multiple biventricular thrombi.

Learning objectives

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Significant systolic dysfunction is unusual, especially in people with prolonged alcoholism.

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The hypercoagulable condition of coronavirus disease 2019 (COVID-19), combined with myocardial damage secondary to alcohol, can result in extensive intracardiac thrombosis.

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Thrombotic manifestations in COVID-19 are associated with a high mortality rate.

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.

Preliminary Evidence for IL-10-Induced ACE2 mRNA Expression in Lung-Derived and Endothelial Cells: Implications for SARS-Cov-2 ARDS Pathogenesis

Angiotensin-converting enzyme 2 (ACE2) is a receptor for the spike protein of SARS-COV-2 that allows viral binding and entry and is expressed on the surface of several pulmonary and non-pulmonary cell types, with induction of a “cytokine storm” upon binding. Other cell types present the receptor and can be infected, including cardiac, renal, intestinal, and endothelial cells. High ACE2 levels protect from inflammation. Despite the relevance of ACE2 levels in COVID-19 pathogenesis, experimental studies to comprehensively address the question of ACE2 regulations are still limited. A relevant observation from the clinic is that, besides the pro-inflammatory cytokines, such as IL-6 and IL-1β, the anti-inflammatory cytokine IL-10 is also elevated in worse prognosis patients. This could represent somehow a “danger signal”, an alarmin from the host organism, given the immuno-regulatory properties of the cytokine. Here, we investigated whether IL-10 could increase ACE2 expression in the lung-derived Calu-3 cell line. We provided preliminary evidence of ACE2 mRNA increase in cells of lung origin in vitro, following IL-10 treatment. Endothelial cell infection by SARS-COV-2 is associated with vasculitis, thromboembolism, and disseminated intravascular coagulation. We confirmed ACE2 expression enhancement by IL-10 treatment also on endothelial cells. The sartans (olmesartan and losartan) showed non-statistically significant ACE2 modulation in Calu-3 and endothelial cells, as compared to untreated control cells. We observed that the antidiabetic biguanide metformin, a putative anti-inflammatory agent, also upregulates ACE2 expression in Calu-3 and endothelial cells. We hypothesized that IL-10 could be a danger signal, and its elevation could possibly represent a feedback mechanism fighting inflammation. Although further confirmatory studies are required, inducing IL-10 upregulation could be clinically relevant in COVID-19-associated acute respiratory distress syndrome (ARDS) and vasculitis, by reinforcing ACE2 levels.