THE TUNNEL-VISION EFFECT OF COVID-19: AN INCIDENTAL DISCOVERY OF SEVERE BICUSPID AORTIC VALVE STENOSIS

Abstract

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bicuspid aortic valve is the most common congenital valvular abnormality, and has an autosomal dominant pattern with incomplete penetrance. Early recognition in the outpatient setting is imperative to prevent the development of aortic stenosis, particularly before it becomes severe. Once the disease progresses to end stage, patients may begin to experience dyspnea on exertion, syncope, and orthopnea. CASE PRESENTATION: We present a case of a 52-year-old male with complaints of shortness of breath, retrosternal chest pain, and nonproductive cough. His dyspnea began 3 months ago, but have progressed to where he felt dyspneic at rest 6 hours prior to admission. He had a positive SARS-CoV-2 PCR two weeks prior at an ancillary testing site. He worked as an iron welder for 37 years, and stated that he hasn't seen a physician in years. Despite a negative SARS-CoV-2 PCR in the ED, he was placed in negative pressure isolation. His initial vitals were BP 114/84, HR 124, RR 36, SpO2 91% on room air, and temperature 102.2 F. There was a loud systolic murmur over the precordium (clearly audible over the ventilation equipment), bibasilar rhonchi on auscultation, minimally elevated JVD, and no bipedal edema. Labs revealed a troponin of 0.152 ng/dL and proBNP 2020 pg/mL, and CXR AP view showed an enlarged cardiac silhouette and minimal bibasilar infiltrate. EKG revealed sinus tachycardia of 120 bpm and LBBB. He was given IVF and IV antibiotics for suspected sepsis due to superimposed bacterial pneumonia. Transthoracic echocardiogram revealed severe bicuspid aortic valve stenosis (velocity 4.01 m/sec, mean PG 42.8 mm Hg, and AVA di 0.75 cm2) and LVEF 30-35%. The following morning, the patient went into flash pulmonary edema requiring urgent intubation and mechanical ventilation. Surprisingly, his repeat SARS-CoV-2 PCR was positive, however his clinical picture was more suggestive of decompensated heart failure rather than active COVID-19. He was aggressively diuresed and extubated 3 days later, and was successfully discharged home with close follow up for possible surgical intervention. DISCUSSION: Bicuspid aortic valve is one of the most significant risk factors leading to severe aortic stenosis (1). Symptoms may remain clinically silent for years, and usually occur only when there is an increase in LVEDP (1). In our case, the patient's recent diagnosis of COVID-19 two weeks prior was a smoke screen of his more insidious underlying valvulopathy. Luckily, he did not succumb to COVID-19, as an international registry of 74 patients with untreated severe aortic stenosis who developed COVID-19 had a mortality of 59.5% and 23.5% for those older and less than 80 years, respectively (2). CONCLUSIONS: It is imperative that we as clinicians remain vigilant and avoid becoming fixated on COVID-19 and its complications, as this may obscure an underlying disease with harmful repercussions if left untreated. REFERENCE #1: Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM 3rd, Thomas JD;American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jun 10;63(22):e57-185. doi: 10.1016/j.jacc.2014.02.536. Epub 2014 Mar 3. Erratum in: J Am Coll Cardiol. 2014 Jun 10;63(22):2489. PMID: 24603191. REFERENCE #2: Danny Dvir, Matheus Simonato, Ignacio Amat-Santos, Azeem Latib, Faraj Kargoli, Luis Nombela-Franco, Marco Agrifoglio, Francesco Giannini, Damiano Regazzoli, Bernhard Reimers, Emmanuel Villa, Victor M. Becerra-Munoz, Marco Mennuni, Andrea Rognoni, Thomas Modine, Lionel Leroux, Rodrigo Estevez-Loureiro, Roberto Nerla, Fausto Castriota, Alfredo Cerillo, Lars Sondergaard, Alessandro Iadanza, Alison Duncan, Flavien Vincent, Massimo Mancone, Lucia Bi tolo, Viviana Maestrini, Luca Testa, Wojtek Wojakowski, Stefano Salizzoni, Vinicius Esteves, Fernanda Mangione, Cleverson Zukowski, Nicolas Amabile, Mony Shuvy & Gregg W. Stone (2021) Severe Valvular Heart Disease and COVID-19: Results from the Multicenter International Valve Disease Registry, Structural Heart, DOI: 10.1080/24748706.2021.1908646 DISCLOSURES: No relevant relationships by Maie Abdullah, source=Web Response No relevant relationships by Nabil Braiteh, source=Web Response No relevant relationships by Kareem Ebeid, source=Web Response No relevant relationships by Altif Muneeb, source=Web Response No relevant relationships by Fnu Shailesh, source=Web Response