Case Presentation
A 70-year-old woman was referred to the Emergency Department of Tehran
Heart Center with chief complaints of typical chest pain and cold
perspiration. Her symptoms had started 4 days earlier, but fever was
added to her presentation on the day of admission. Unfortunately, due to
the panic among the general population regarding the transmission of
COVID-19, the patient ignored her symptoms at the beginning; she came
just after increasing in the severity and frequency of her chest pain.
Physical examination revealed a body temperature of 38.6°C, a
respiratory rate of 20 per minute, a blood pressure of 100/65 mm Hg, a
heart rate of 110 bpm, and an O2 saturation level of
89%. The patient was ill and appeared toxic; nonetheless, she had a
normal consciousness level and was well-oriented.
She has previous history of diabetes mellitus, hypertension, and
dyslipidemia. Additionally, she had undergone coronary artery bypass
graft surgery two years ago in this hospital.
Electrocardiography on admission illustrated sinus tachycardia,
generalized ST- depressions, and ST-elevations in aVR and
V1 ; all in favor of a left-main pattern or multi-vessel
ischemia. She subsequently underwent echocardiography, which
demonstrated a left ventricular ejection fraction (LVEF) of 45%, mild
right ventricular (RV) dysfunction, and moderate mitral and tricuspid
regurgitation. The patient’s echocardiogram obtained a year before was
almost the same, except for mild tricuspid regurgitation.
An interventional cardiologist was consulted immediately. Given the
patient’s age, fever, and suspicion of COVID-19, a decision was made to
administer full anticoagulant and anti-ischemic therapy and obtain a
chest computed tomography (CT) scan. Her chest pain subsided and she
became stable; nevertheless, she remained febrile. The patient underwent
another chest CT scan (Fig. 1), which showed mild-to-moderate pleural
effusion. Based on her symptoms, a real-time reverse
transcription-polymerase chain reaction (rRT-PCR) test for COVID-19 was
requested, and hydroxychloroquine was initiated based on infectious
disease consultation.
Ten hours later (the next day), the patient experienced an increase in
her chest pain. She was transferred to the catheterization laboratory.
The anastomosis of the left internal mammary artery to the left anterior
descending artery was opened, but the anastomosis of the saphenous vein
graft to the left circumflex artery (LCX) was occluded
and the LCX was 90–99% stenotic. Percutaneous coronary
intervention (PCI) was performed on the LCX. Post
procedurally, the patient experienced a relief in her chest pain and
became stable, but her fever persisted and her O2saturation level was 89-90%. Dry coughs became more prominent. The
second spiral chest CT scan was compatible with COVID-19, and the
rRT-PCR result was also positive for COVID-19. Accordingly,
lopinavir/ritonavir (KALETRA) was added to her drug regimen, and
O2 therapy under the supervision of an anesthesiologist
was continued. Her laboratory tests revealed a white blood cell count of
10,700, a lymphocyte count of 1070, a C-reactive protein level of 2.5
(> 0.5 mg/dL), a creatinine level of 2.1 mg/dL, a brain
natriuretic peptide level of 530 pg/mL, and a troponin level of 269
ng/L. Her blood culture was negative.
After 10 days of treatment with anti-corona drugs, the patient’s
symptoms worsened and her O2 saturation level dropped to
70%. Chest CT scan illustrated diffuse ground-glass pattern in the
parenchyma. This chest CT scan was discernibly worse than the previous
one.
In the meantime, the patient’s persistent post-PCI tachycardia, hypoxia,
and moderate immobility urged us to investigate other possible causes of
hypoxia such as tamponade, mechanical complications of myocardial
infarction, and acute pulmonary thromboembolism (PTE). In addition, she
experienced weakness and paresthesia of the right arm. Bedside
echocardiography showed an LVEF of 40-45%, moderate RV dysfunction,
moderate mitral regurgitation, and severe tricuspid regurgitation.
Pulmonary CT angiography demonstrated bilateral, lobar PTE with an RV/LV
of about 0.93 (Fig. 2). As the patient had been on prophylactic heparin
since PCI, the therapeutic dosage was resumed. Unfortunately, in Brain
CT a hypo-dense area in left parietooccipital area and also semiovale
area in favor of watershed infarct was noted (Fig. 2).
Fortunately, she survived and was discharged from the hospital in an
acceptable condition and with stable vital signs. The diagnosis of PTE
and initiation of therapeutic heparin clearly improved her condition.
Stroke rehabilitation was started from hospital and requested in
outpatient visits.