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Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: COVID-19 is associated with arterial and venous thrombosis with incidence of 2.3-22% in severe cases and 0-6% in mild cases. Very few case reports exist about cardiac thrombus in COVID-19 patients with Myocardial infarction (MI) but our patient purely had increased thromboembolic risk from COVID-19 without MI. CASE PRESENTATION: A 49-year-old male with a history of HTN, IDDM, CKD stage 3, and asthma presented to the hospital with six days of progressive dyspnea with fever, fatigue, and cough. He tested positive for COVID-19 two days prior. He was hypoxic at 83% on room air. Pertinent physical exam revealed coarse breath sounds bilaterally and no murmurs. Lab work showed creatinine 1.93 mg/dl, troponin 0.357 ng/ml, B-natriuretic peptide (BNP) 275 pg/ml. D-dimer 1,369 ng/ml, Ferritin 1,569 ng/ml, and CRP >8 mg/dl. Chest x-ray showed bilateral patchy nodular opacities. CTA chest showed pneumonia and bilateral effusions without pulmonary embolism. The patient was started on oxygen supplementation, dexamethasone, and enoxaparin 30 mg every 12 hours. On day 2, Remdesivir was initiated as kidney function had improved. The enoxaparin dose was increased to 0.5mg/kg (60 mg every 12 hours) due to worsening D-dimer at 2268 ng/ml. On day 3, he had worsening respiratory failure and was transitioned to a high flow respiratory system on 60L. Repeat BNP increased to 475.4 pg/ml and D-dimer to >7650 ng/ml. Troponin plateaued at 0.3 ng/ml. He was switched to a low-intensity heparin protocol of 10 units/kg/hr. A trans-thoracic echocardiogram (TTE) showed an ejection fraction of 57% with a questionable apical clot and without wall motion abnormality. A TTE with contrast showed a spherical echogenic mass 1.87 x 1.64 cm, consistent with left ventricular (LV) thrombus attached to the septum. He was then switched to a high-intensity heparin protocol of 15 units/kg/hr and then transitioned to warfarin with a plan for outpatient cardiac MRI. On day 11, he was discharged home on 2L of oxygen. DISCUSSION: Thromboembolic disease is a well-known complication of COVID-19. The pathophysiology of thromboembolism in COVID-19 is multifactorial including platelet dysfunction, viral-mediated endothelial inflammation, hypercoagulability, and acquired antiphospholipid antibodies.LV thrombus is a known complication of MI and dilated cardiomyopathy but our patient did not have associated MI. His only apparent predisposing factor was hypercoagulability due to COVID-19. TTE with contrast increases the visibility of the thrombus. But, cardiac MRI with contrast remains the gold standard for its diagnosis. Anticoagulation is the mainstay of treatment as it reduces the major adverse cardiac events (MACE) and overall mortality. CONCLUSIONS: Cardiac thrombus is a rare thromboembolic phenomenon that needs to be considered in COVID-19 patients with or without MI. Immediate parenteral anticoagulation is key for reducing complications. REFERENCE #1: Roberts KA, Colley L, Agbaedeng TA, Ellison-Hughes GM, Ross MD. Vascular Manifestations of COVID-19 – Thromboembolism and Microvascular Dysfunction. Front Cardiovasc Med. 2020;7:598400. doi:10.3389/fcvm.2020.598400 REFERENCE #2: Ackermann M, Verleden SE, Kuehnel M, et al. Pulmonary Vascular Endothelialitis, Thrombosis, and Angiogenesis in Covid-19. N Engl J Med. 2020;383(2):120-128. doi:10.1056/NEJMoa2015432 REFERENCE #3: Jadhav KP, Jariwala P. Intra-Cardiac Thrombus in COVID-19 pandemic – Case Series and Review. Eur J Cardiovasc Med. Published online November 23, 2020. doi:10.5083/ejcm20424884.180 DISCLOSURES: No relevant relationships by Tundun babalola, source=Web Response No relevant relationships by Francis Jenkins, source=Web Response No relevant relationships by Nirvi Shah, source=Web Response No relevant relationships by Shraddha Tongia, source=Web Response