A Severe COVID-19 Case Complicated by Right Atrium Thrombus

Abstract

Patient: Male, 73-year-old Final Diagnosis: Severe COVID-19 pneumonia complicated by right atrium thrombus Symptoms: Fever • dyspnea • cough Medication:— Clinical Procedure: — Specialty: Critical Care Medicine Objective: Educational purpose Background: Recent studies demonstrated evidence of coagulation dysfunction in hospitalized patients with severe coronavirus disease 2019 (COVID-19) due to excessive inflammation, hypoxia, platelet activation, endothelial dysfunction, and stasis. Effective anticoagulation therapy may play a dominant role in the management of severe COVID-19 cases. Case Report: A 73-year-old man with a 6-day history of fever up to 38.5°C, dyspnea, cough, and fatigue was diagnosed with COVID-19. He had a past medical history significant for hypertension and coronary artery bypass grafting. Two days after hospital admission, the patient developed acute respiratory failure, requiring intubation, mechanical ventilation, and transfer to the intensive care unit (ICU). He received treatment including antibiotics, hydroxychloroquine, tocilizumab, vasopressors, prone positioning, and anticoagulation with enoxaparin at a prophylactic dose. After a 15-day ICU stay, the patient was hemodynamically stable but still hypoxemic; a transthoracic echocardiogram at that time, followed by a transesophageal echocardiogram for better evaluation, revealed the presence of a right atrium thrombus without signs of acute right ventricular dilatation and impaired systolic function. Since the patient was hemodynamically stable, we decided to treat him with conventional anticoagulation under close monitoring for signs of hemodynamic deterioration; thus, the prophylactic dose of enoxaparin was replaced by therapeutic dosing, which was a key component of the patient’s successful outcome. Over the next few days he showed significant clinical improvement. The follow-up transesophageal echo-cardiogram 3 weeks after effective therapeutic anticoagulation revealed no signs of right heart thrombus. Conclusions: The presented COVID-19 case, one of the first reported cases with evidence of right heart thrombus by transesophageal echocardiography, highlights the central role of diagnostic imaging strategies and the importance of adequate anticoagulation therapy in the management of severe COVID-19 cases in the ICU.

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

“…The treatment of patients who have had thrombosis of the right atrium in SARS-CoV-2 and given the condition of the patients, in particular our patient, is based on anticoagulation at a curative dose with the hope of having a complete dissolution of the thrombi [35]. Ventricular rhythmic dysfunction is observed in 50% of patients [36], and numerous arrhythmias have been documented, including atrial fibrillation, premature ventricular contractions, and prolongation of the QT interval, cases of varying degrees of atrial block ventricles have been described [37,38].…”

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

“…Previous reports have already demonstrated the presence of intracardiac thrombi detected through echocardiography in the evaluation of patients with severe COVID-19 9 ; this has led to a consensus about the importance of echocardiographic images for the evaluation and monitoring of these patients, since thrombotic events in patients with COVID-19 are related to a worse prognosis 10 .…”

“…Previous reports have already demonstrated the presence of intracardiac thrombi detected through echocardiography in the evaluation of patients with severe COVID-19 9 ; this has led to a consensus about the importance of echocardiographic images for the evaluation and monitoring of these patients, since thrombotic events in patients with COVID-19 are related to a worse prognosis 10 . These thrombotic events are mostly related to the presence of SARS-CoV-2 in the airways, which can unleash an innate immune response mediated initially by macrophages that generate a disproportionate immune response causing endotheliitis and the formation of microthrombi.…”

Perspectives in vaccines, immune response, therapeutic interventions and COVID-19

“…Recent research has made significant progress in elucidating a plethora of pathophysiologic mechanisms of COVID-19 infection, which has revealed as not merely a respiratory infection but rather a multisystem disease with various complications [ 38 , 39 ]. Furthermore, the inflammatory response during COVID-19 may be characterized as a cytokine storm that is associated with sepsis and septic shock [ 40 , 41 ].…”