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.