Clot in Transit in a Patient with COVID-19: Transesophageal Echocardiographic Guidance of Mechanical Cardiopulmonary Resuscitation

Horowitz, James; Yuriditsky, Eugene; Bakker, Jan; Magda, Gabriela; Teran, Felipe; Sarić, Muhamed

doi:10.1016/j.case.2020.12.003

Cited by 4 publications

(3 citation statements)

References 11 publications

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“…It allows for the rapid detection of right heart thrombus treatment in a timely manner. This critical role of TTE has been recently demonstrated in several cases [ 16 , 17 ].…”

Section: Discussionmentioning

confidence: 90%

Right Ventricular Clot in Transit in a Patient with Coronavirus Disease 2019 (COVID-19) Pneumonia Successfully Treated with Thrombolytics

Alali

Jackson

Anani

et al. 2022

Case Reports in Critical Care

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Background. Right heart thrombus or clot in transit is a rare venous thromboembolism (VTE) with high mortality. COVID-19 infection has been associated with increased risk of such events. We present the case of a 63-year-old man with no traditional VTE risk factors who was diagnosed with a clot in transit three weeks after diagnosis of COVID-19. Clinical Case. A 63-year-old male with no significant past medical history who presented to the emergency department with shortness of breath. He tested positive for COVID-19 three weeks prior. His oxygen saturation was 60% on room air and was put on nonrebreather mask. He was still showing signs of respiratory distress including tachypnea, tachycardia, diaphoresis, and accessory muscle use. The patient was subsequently intubated and mechanically ventilated. Chest computed tomography with contrast showed acute bilateral pulmonary emboli with flattening of the interventricular septum suggestive of right heart strain. Bedside echocardiogram showed severely enlarged right ventricle with reduced systolic function and evidence of right ventricular strain and a mobile echodensity in the right ventricle attached to the tricuspid valve consistent with a clot in transit. The patient was treated with full dose systemic thrombolysis with rapid improvement in his symptoms. He was extubated the following day and a repeat echocardiogram showed resolution of the clot in transit. Conclusion. Clot in transit is rare but can occur in COVID-19 patients even in the absence of traditional thromboembolism risk factors. Management includes systemic anticoagulation, systemic thrombolysis, and surgical embolectomy. Our patient was successfully treated with systemic thrombolysis.

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“…It allows for the rapid detection of right heart thrombus treatment in a timely manner. This critical role of TTE has been recently demonstrated in several cases [ 16 , 17 ].…”

Section: Discussionmentioning

confidence: 90%

Right Ventricular Clot in Transit in a Patient with Coronavirus Disease 2019 (COVID-19) Pneumonia Successfully Treated with Thrombolytics

Alali

Jackson

Anani

et al. 2022

Case Reports in Critical Care

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“…In many cases, ccTEE was reported to help clarify the etiology of shock ( Table 3 ). ccTEE was used to correctly identify right ventricular (RV) failure from acute pulmonary embolism, 30 – 34 for managing the peripartum patient with hemodynamic collapse, 35 , 36 and for identifying unexpected causes of shock like dynamic left ventricular outflow tract (LVOT) obstruction. 37 , 38 There were a number of case reports of ccTEE identifying rare causes of shock that may not have been visualized on TTE: right atrial compression from intrabdominal hematoma, 39 thoracic tamponade post lung transplant, 40 and regional pericardial tamponade in the ED after discharge home from cardiac surgery.…”

Section: Resultsmentioning

confidence: 99%

“…42,43,82 Perhaps the most powerful application of ccTEE is its ability to quickly phenotype shock and identify causes that have targeted treatments such as pulmonary embolism, effusion, or severe ventricular dysfunction. [30][31][32][33][34][35][36][37][38][39][40]83,84 Its use to phenotype shock is valuable even when only core "resuscitative" TEE views are used, although refining management often requires additional views and quantitative measurements. A simplified "resuscitative" ccTEE protocol like the one shown in Figure 2 allows for the assessment of LV and RV function, pericardial disease, and catastrophic valvular failure.…”

Section: Discussionmentioning

confidence: 99%

Indications, Clinical Impact, and Complications of Critical Care Transesophageal Echocardiography: A Scoping Review

Prager

Bowdridge

Pratte

et al. 2022

J Intensive Care Med

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Background Critical care transesophageal echocardiography (ccTEE) is an increasingly popular tool used by intensivists to characterize and manage hemodynamics at the bedside. Its usage appears to be driven by expanded diagnostic scope as well as the limitations of transthoracic echocardiography (TTE) – lack of acoustic windows, patient positioning, and competing clinical interests (eg, the need to perform chest compressions). The objectives of this scoping review were to determine the indications, clinical impact, and complications of ccTEE. Methods MEDLINE, EMBASE, Cochrane, and six major conferences were searched without a time or language restriction on March 31st, 2021. Studies were included if they assessed TEE performed for adult critically ill patients by intensivists, emergency physicians, or anesthesiologists. Intraoperative or post-cardiac surgical TEE studies were excluded. Study demographics, indication for TEE, main results, and complications were extracted in duplicate. Results Of the 4403 abstracts screened, 289 studies underwent full-text review, with 108 studies (6739 patients) included. Most studies were retrospective (66%), performed in academic centers (84%), in the intensive care unit (73%), and were observational (55%). The most common indications for ccTEE were hemodynamic instability, trauma, cardiac arrest, respiratory failure, and procedural guidance. Across multiple indications, ccTEE was reported to change the diagnosis in 52% to 78% of patients and change management in 32% to79% patients. During cardiac arrest, ccTEE identified the cause of arrest in 25% to 35% of cases. Complications of ccTEE included two cases of significant gastrointestinal bleeding requiring intervention, but no other major complications (death or esophageal perforation) reported. Conclusions The use of ccTEE has been described for the diagnosis and management of a broad range of clinical problems. Overall, ccTEE was commonly reported to offer additional diagnostic yield beyond TTE with a low observed complication rate. Additional high quality ccTEE studies will permit stronger conclusions and a more precise understanding of the trends observed in this scoping review.

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Heparin

2022

Reactions Weekly

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Lack of efficacy : case reportA 34-year-old man exhibited lack of efficacy while receiving heparin as thromboprophylaxis therapy. The man presented to emergency department with a 1-week history of cough and dyspnoea. Following admission, he was tested positive for severe acute respiratory syndrome coronavirus 2 by polymerase chain reaction. Chest radiograph findings were consistent with COVID-19 pneumonia. He was emergently intubated and transferred to the ICU. Thereafter, he started receiving off-label treatment with azithromycin, hydroxychloroquine and tocilizumab. Additionally, he started SC heparin for thromboprophylaxis [dosage not stated]. Over the next 3 days, he had gradual improvement. However, on the day 4, he developed supraventricular tachycardia and hypotension, which required emergent cardioversion. An ultrasound showed severe right ventricular (RV) dilation and hypokinesis with a clot in transit (CIT) in the right heart, despite thromboprophylaxis with heparin. Soon afterwards, he developed pulseless electrical activity and cardiopulmonary resuscitation (CPR) was initiated. On transesophageal echocardiography (TEE) a large CIT was noted in the right atrium during active CPR. Under TEE guidance, the mechanical CPR device was moved caudally transitioning the AMC toward the body of the left ventricle. In spite of extensive resuscitative efforts, he developed an agonal rhythm and expired thereafter.

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Clot in Transit in a Patient with COVID-19: Transesophageal Echocardiographic Guidance of Mechanical Cardiopulmonary Resuscitation

Cited by 4 publications

References 11 publications

Right Ventricular Clot in Transit in a Patient with Coronavirus Disease 2019 (COVID-19) Pneumonia Successfully Treated with Thrombolytics

Right Ventricular Clot in Transit in a Patient with Coronavirus Disease 2019 (COVID-19) Pneumonia Successfully Treated with Thrombolytics

Indications, Clinical Impact, and Complications of Critical Care Transesophageal Echocardiography: A Scoping Review

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