CASE SERIES |
https://doi.org/10.5005/jp-journals-11006-0079 |
Right Ventricle Thrombus and COVID-19 Infection: An Uncommon Report of Three Cases
1,2,11–16Department of Critical Care Medicine, Bhailal Amin General Hospital, Vadodara, Gujarat, India
3Department of Microbiology, Smt BK Shah Medical Institute & Research Centre, Vadodara, Gujarat, India
4,5Department of Pulmonology, Bhailal Amin General Hospital, Vadodara, Gujarat, India
6–8Department of Internal Medicine, Bhailal Amin General Hospital, Vadodara, Gujarat, India
9,10Department of Cardiology, Bhailal Amin General Hospital, Vadodara, Gujarat, India
Corresponding Author: Bhavinkumar Patel, Department of Critical Care Medicine, Bhailal Amin General Hospital, Vadodara, Gujarat, India, Phone: +91 9998979267, e-mail: drbhavin007@gmail.com
Received on: 20 July 2023; Accepted on: 19 October 2023; Published on: 01 December 2023
ABSTRACT
A report of three patients with severe coronavirus disease 2019 (COVID-19) infection and right ventricle thrombus is being presented. All of them were thrombolyzed, out of which two patients survived. Based on various studies and supporting our case series, we advocate a low threshold of 2D-echocardiogram (2D-echo) screening, especially in those patients having disproportionate oxygen requirements. More studies are required to prove that early thrombolysis may be beneficial in COVID-19 patients with right ventricular thrombus (RVT).
How to cite this article: Patel B, Umraniya P, Patel R, et al. Right Ventricle Thrombus and COVID-19 Infection: An Uncommon Report of Three Cases. Indian J Crit Care Case Rep 2023;2(6):158–160.
Source of support: Nil
Conflict of interest: None
Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.
Keywords: Coronavirus disease 2019, Coronavirus, Right ventricle thrombus, Severe acute respiratory syndrome coronavirus 2, Thrombotic
INTRODUCTION
Right ventricular thrombus (RVT) is a rare but potentially life-threatening complication of various cardiac and systemic disorders, including coronavirus disease 2019 (COVID-19) infection. RVT can cause serious adverse outcomes such as systemic embolization, cardiogenic shock, and sudden cardiac death. While the occurrence of a ventricular thrombus in COVID-19 patients with pulmonary embolism is relatively uncommon, with only a 4% incidence rate, it is important to note that mortality rates can soar as high as 29%. Our study provides insights into the challenging diagnosis and management of RVT, shedding light on the poorly understood epidemiology and prognosis of RVT. Specifically, we describe the clinical characteristics, diagnostic methods, treatment modalities, and outcomes of patients with RVT.
CASE DESCRIPTION
Case 1
A 43-year-old diabetic and hypertensive male presented to our hospital with severe COVID-19 pneumonia. On admission, vitals were within normal limits. Respiratory rate was 20–24/minute with SpO2 at 92% on 4 L of O2 delivered through nasal prong. Bilateral air entry was present in the lungs with crackles present on auscultation. All baseline investigations were done. C-reactive protein (CRP), D-dimer, and ferritin were elevated. Chest X-ray showed bilateral peripheral haziness, predominant basal involvement, and suggestive of severe pneumonia. Rest of the investigations and 2D-echocardiogram (2D-echo) were normal. On the day of admission, oxygen requirement was around 4 L/minute, patient had received convalescent plasma for 2 days, as patients D-dimer on arrival was >10,000 ng/mL. Enoxaparin was continued at therapeutic dose. Within 24–48 hours, hypoxia worsened, and he was kept on NIV support at 90% oxygen. Patient was investigated, showing D-dimer continued to be >10,0000 ng/mL. A repeat 2D-echo suggested RVT (Video 1), but bilateral lower limb Doppler failed to reveal any evidence of deep vein thrombosis. Patient was thrombolyzed with 100 mg injection actilyse [recombinant tissue plasminogen activator (rt-PA)] over 2 hours. 2D-echo was repeated again (Video 2) and showed reduction in the size of thrombus. After 10 days, oxygen requirement was reduced to 5–6 L/minute, and in another 10–11 days, patient was shifted out of ICU and was finally discharged after 24 days of admission. Following discharge, patient was advised to take dabigatran 150 mg 12 hourly.
Case 2
A 29-year-old obese female presented with severe COVID-19 pneumonia, with SpO2 at 67% on room air and SpO2 at 95% with 6 L/minute O2 on mask in intensive care unit. Her oxygen requirement increased within 36–48 hours after admission. Patient’s first 2D-echo on admission was normal. As patient oxygen requirement was increasing along with respiratory distress, 2D-echo was repeated again, showing 15*16 mm right apical thrombus with left ventricular ejection fraction LVEF at 60%. Bilateral lower limb Doppler was negative for deep vein thrombosis. Patient was kept on high-flow nasal cannula (HFNC) with FiO2 at 0.6 and was thrombolyzed with injection rt-PA (actilyse) 100 mg over 2 hours. She was gradually stabilized over a period of 7–10 days, and her oxygen requirement decreased. Patient was discharged after 28 days with oral anticoagulants.
Case 3
A 38-year-old male presented to our hospital with severe COVID pneumonia, with SpO2 at 88% on room air and SpO2 at 94% with 8–10 L/minute of oxygen on mask. Patient’s investigations were normal; only CRP was elevated. High-resolution computed tomography (HRCT) showed CT severity of 17/25. On the 8th day, patient received injection casirivimab + injection dexirab antibody. He was gradually improving, but on the 11th day, there was a sudden increase in oxygen requirement on nonrebreathing mask (NRBM) 15 L/minute, followed by HFNC and intermittent noninvasive ventilation (NIV) support. His CRP, D-dimer, and interleukin 6 (>5,000 pg/mL) were increased, dexamethasone was changed to injection methylprednisolone 40 mg twice a day along with injection tocilizumab 400 mg given twice at 24-hour intervals. The patient gradually improved and his oxygen requirement was decreased to 8–10 L/minute; CRP and D-dimer also started declining. On 18th day, patient’s oxygen requirement again increased, and he needed NIV support with FiO2 at 1.0. Patient was intubated on the same day in view of worsening respiratory distress; CT pulmonary angiography (Fig. 1) was done, which showed massive thrombus in right ventricle extending to right descending pulmonary artery, segmental, subsegmental branches, and left pulmonary artery and its segmental branches. Bilateral lower limb Doppler did not show any evidence of deep vein thrombosis; injection rt-PA (actilyse) 100 mg was given over 2 hours. After sending blood, endotracheal and urine c/s samples, antibiotics were stepped up to injection polymyxin B and teicoplanin. Additionally, low-molecular-weight heparin in therapeutic dose was continued throughout the course of management. In view of hemodynamic instability, extracorporeal blood purification (CytoSorb) was also initiated, but patient could not be salvaged.
Fig. 1: CT image of right ventricle thrombus
DISCUSSION
In COVID-19 pandemic, we found strong association between infection and hypercoagulopathy.1 In severe cases of COVID-19, thrombotic tendency seems to be one of the most dreadful consequences of the disease. Many studies revealed that nearly 0.25% of patients who were critically ill had thromboembolic phenomenon.2
Coronavirus disease 2019 (COVID-19)-associated coagulopathy (CAC) is related to direct effect of viral infection, systemic inflammatory response, neutrophil extracellular trap, and complement activation. In severe COVID-19 infection, there is loss in coagulation regulatory mechanism, which leads to disseminated microthrombosis, causing a consumptive coagulopathy. Due to the observed association between mortality, thrombosis, and coagulation marker along with D-dimmer, it is advisable to administer at least prophylactic dose of anticoagulation to the hospitalized patients with COVID-19. Abnormal coagulation parameters, combined with severe COVID-19-related thrombosis, serve as unfavorable prognostic indicators.
As per Mui et al., moderate to severe COVID-19 patients are likely to have some form of thromboembolic events, which may be life-threatening in some cases.2 Avila et al. also supported the evidence of thrombotic complications of COVID-19 infection.3
In our case series, we suggest maintaining a low threshold for screening intracardiac thrombus using 2D-echo as demonstrated by Subramanyam et al.,4 Mitsis et al.,5 and Ramalho et al.6 These studies revealed instances of RVT and left ventricular thrombus as well as thrombus attachment to valves such as the pulmonary valve.7,8 Considering that intracardiac thrombus is not an uncommon condition, routine screening using 2D-echo proves to be highly beneficial. Various modalities available for managing RVT include anticoagulation, surgical embolectomy, and systemic thrombolysis.9,10
High index of suspicion and early treatment is very much necessary to avoid poor outcomes and mortality in such severe cases.11,12 In severe cases of COVID-19 infections, especially with right heart thrombus and pulmonary embolism, thrombolysis should be done as soon as possible.13 Additional research is warranted to explore the screening and thrombolysis approaches, particularly in cases of severe COVID-19 infection accompanied by RVT.
CONCLUSION
In this case series of COVID-19, we found that 2D-echo facilitated the timely diagnosis of right ventricle thrombus. We also observed that these cases had quick and good outcomes with early fibrinolytic treatment. Further studies are needed to determine the early diagnosis and optimal management of right ventricle thrombus in COVID-19 infection with high oxygen requirement.
Clinical Significance
Routine 2D-echo screening should be conducted alongside other blood investigations whenever there is an acute increase in oxygen requirement during periods of clinical stability in COVID-19 infections. Our case series suggests that low threshold for echo screening and early thrombolytic therapy may be lifesaving.
SUPPLEMENTARY MATERIAL
The supplementary videos 1 and 2 are available online on the website of www.ijccr.org
Video 1: Prethrombolysis 2 D echo for right ventricle thrombus
Video 2: Postthrombolysis 2 D echo
ORCID
Bhavinkumar Patel https://orcid.org/0000-0001-5070-9315
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