Case presentation
A 67-year-old female with a history of obesity, gastric acid reflux
disease, and hiatal hernia repair presented with persistent chest pain
of 1-day duration. Her husband had weakness and fatigue of 1-week
duration. Laboratory testing is presented in Figure . Given
exposure to her husband who had non-specific symptoms, nasal swab
testing for the SARS-CoV-2 was done which returned positive. She did not
have respiratory symptoms, hypoxia, or fevers suggestive of COVID-19
pneumonia. Chest radiography showed clear lung fields (Figure
Panel A) . She was admitted for a non-ST elevation myocardial
infarction. Cardiac catheterization revealed severe three-vessel
coronary artery disease (CAD), a culprit lesion in a large branching
first diagonal with complete occlusion and grade 2 left to left
collaterals; diffuse, severe, proximal and mid-left anterior descending
artery CAD, and severe proximal right coronary artery CAD. There was
severe distal left circumflex and left posterior descending artery CAD.
Echocardiography revealed normal ventricular function and wall motion.
In the setting of continued symptoms from the acute coronary syndrome
and multivessel CAD, cardiac surgical consultation was requested.
Laboratory testing to identify inflammatory markers elevations
associated with COVID-19 were normal; Figure. Computed
tomographic (CT) chest imaging confirmed clear lung fields without
pulmonary parenchymal pathology (Figure Panel B) . After ruling
out active COVID-19 infection, we decided to proceed with CABG surgery.
Following uneventful induction of general anesthesia, aorta-bicaval
cannulation was utilized for cardiopulmonary bypass. Myocardium was
protected with cold blood cardioplegia. Coronary revascularization was
performed with an in situ left internal mammary arterial graft to
the left anterior descending artery, saphenous venous graft to the first
diagonal, and saphenous venous graft to the left posterior descending
artery. The patient was weaned from cardiopulmonary bypass without
difficulty and transferred to the ICU. She was extubated within 4 hours
of ICU admission and transitioned to nasal cannula oxygen at 2 L/min.
Acute blood loss anemia was managed with transfusion\souts.
Post-operative day 1 chest radiograph showed atelectasis which was
managed with incentive spirometry and pain control. Subsequent
radiographs showed the development of bilateral small pleural effusions
(Figure Panel C), accompanied by the requirement for increase
in nasal oxygen support to 5 L/min. The effusions were successfully
treated with furosemide. The patient was then transferred to the
step-down unit on post-operative day 4. She was afebrile during this
period with no significant laboratory abnormalities. Respiratory status
continued to improve, with improvement in chest radiography findings and
nasal oxygen support was gradually weaned off (Figure Panel D ).
The patient was discharged home on post-operative day 6.