Saddle pulmonary embolism and clot in transit in COVID-19 infection: a case report of catastrophic venous thromboembolism

Abstract

Background Coronavirus disease 2019 (COVID-19) is associated with a coagulopathy favouring thrombosis over bleeding that imparts a poor prognosis. Clot in transit (CIT) is considered a rare entity and the most severe form of venous thromboembolism (VTE), carrying a higher mortality than isolated pulmonary embolism (PE). The incidence of this phenomenon in patients with COVID-19 infection is unknown and likely under-recognized. Case summary During the peak of the COVID-19 pandemic in New York City, a 70-year-old Hispanic female presented with syncope due to a saddle PE further complicated by a highly mobile CIT. Polymerase chain reaction was positive for COVID-19 infection, however, there was no evidence of lung parenchymal involvement or hyper-inflammation. Based on consensus from a multidisciplinary team, aspiration thrombectomy was attempted to treat this extreme case of VTE, however, the patient died during the procedure. Discussion This case raises awareness to the most catastrophic form of VTE, presenting in an early phase of COVID-19 infection without the typical hyper-inflammation and severe lung injury associated with development of COVID-related coagulopathy. It also serves to inform on the critical role echocardiography has in the comprehensive evaluation and re-evaluation of hospitalized patients with COVID-19, and the importance of a multidisciplinary organized approach in clinical decision-making for this complex and poorly understood disease and its sequelae.

Syncope and COVID-19 disease – A systematic review

“…The majority of studies, 16, described syncopal episodes of unexplained etiology (Romero-Sánchez et al, 2020, Pérez et al, 2020, Chachkhiani et al, 2020, Xiong et al, 2020, Radmanesh et al, 2020, Chuang et al, 2021, Pérez et al, 2020Mizrahi et al, 2020, Martín-Sánchez et al, 2020, Travi et al, 2020, Argenziano et al, 2020, Gonfiotti et al, 2020, García-Moncó et al, 2020, Chen et al, 2020, Lam et al, 2020, Chou et al, 2021. 10 case reports alluded to possible cardiac etiology for syncope (Sang et al, 2020, Pasquetto et al, 2020, Luetkens et al, 2020, Chang et al, 2020, Khan et al, 2020, Chalela et al, 2020, Chibane et al, 2020, Pendower et al, 2020, Aoi et al, 2020, Doodnauth et al, 2021 as well as 1 case series (Espinoza et al, 2021), while another 6 studies attributed the cause of syncope to orthostatic hypotension (Ebrille et al, 2020, Tapé et al, 2013, Logmin et al, 2020, Singhania et al, 2020, Huang et al, 2020, Omotosho et al, 2021. In turn, reflex syncope was highlighted in only 3 of the studies (Ebrille et al, 2020, Canetta et al, 2020, Birlutiu et al, 2020.…”

“…Of the 37 included articles, 18 were case reports (Tapé et al, 2013, Sang et al, 2020, Pasquetto et al, 2020, Luetkens et al, 2020, Logmin et al, 2020, Chang et al, 2020, Singhania et al, 2020, Huang et al, 2020, Omotosho et al, 2021, Khan et al, 2020, Chalela et al, 2020, Pérez et al, 2020, Chibane et al, 2020, Pendower et al, 2020, Aoi et al, 2020, Doodnauth et al, 2021, Kanjwal et al, 2020, Miglis et al, 2020, 10 were retrospective analyses (Oates et al, 2020, Romero-Sánchez et al, 2020, Chachkhiani et al, 2020, Xiong et al, 2020, Radmanesh et al, 2020, Canetta et al, 2020, Chuang et al, 2021, Mizrahi et al, 2020, Martín-Sánchez et al, 2020, Travi et al, 2020, 5 were case-series (Ebrille et al, 2020, Birlutiu et al, 2020, Argenziano et al, 2020, Espinoza et al, 2021, Gonfiotti et al, 2020 and 2 were prospective studies (García-Moncó et al, 2020, Chen et al, 2020. One was a letter (Lam et al, 2020).…”

“…Regarding the comorbidities of patients with COVID-19 and syncope, arterial hypertension was heavily represented in 21 studies (Oates et al, 2020, Ebrille et al, 2020, Romero-Sánchez et al, 2020, Tapé et al, 2013, Sang et al, 2020, Singhania et al, 2020, Pérez et al, 2020, Aoi et al, 2020, Doodnauth et al, 2021, Chachkhiani et al, 2020, Canetta et al, 2020, Chuang et al, 2021, Mizrahi et al, 2020, Martín-Sánchez et al, 2020, Travi et al, 2020, Birlutiu et al, 2020, Argenziano et al, 2020, Espinoza et al, 2021, Gonfiotti et al, 2020, García-Moncó et al, 2020, Lam et al, 2020, making it the most prevalent comorbid condition exhibited by the participants. This was followed by Diabetes mellitus, obesity, dyslipidemia and heart disease.…”

“…Out of the 18 case reports, syncope was the reason that prompted the visit to the Emergency Department in 13 of them (72.2%) (Tapé et al, 2013, Pasquetto et al, 2020, Luetkens et al, 2020, Logmin et al, 2020, Chang et al, 2020, Singhania et al, 2020, Huang et al, 2020, Chalela et al, 2020, Pérez et al, 2020, Chibane et al, 2020, Pendower et al, 2020, Aoi et al, 2020, Doodnauth et al, 2021. Furthermore, Ebrille et al (2020), Canetta et al (2020) and Espinoza et al (2021) also described syncope as the presenting symptom of the infection.…”

“…Considering confirmed or presumable cardiac syncope, the 13 reported cases included myocarditis (Luetkens et al, 2020), pulmonary embolisms (Khan et al, 2020, Chalela et al, 2020, Chibane et al, 2020, Pendower et al, 2020, Aoi et al, 2020 and ventricular fibrillation (Sang et al, 2020), Brugada Syndrome (Chang et al, 2020, Pasquetto et al, 2020, new onset atrial fibrillation together with anterior wall ST elevation myocardial infarction (Oates et al, 2020), sinus node dysfunction (Doodnauth et al, 2021), non-sustained tachycardia (Espinoza et al, 2021) and sinus bradycardia (Espinoza et al, 2021) as the underlying conditions.…”