Case Report
A 33-year old man without any known comorbidities presented with dyspnoea to our tertiary center. He tested positive for COVID-19 two weeks prior to admission during a business trip in Asia. With progressive deterioration in his lung function, he was intubated and mechanically ventilated in a prone position in accordance with guidelines for the management of Acute Respiratory Distress Syndrome (ARDS). Brain and thoracic computed tomography (CT) scanning were performed to investigate a persistent neurological deficit following sedation withdrawal, and demonstrated a large left-sided ischemic stroke (Figure 1 A) with extensive central pulmonary embolism (Figure 1 B). The patient subsequently developed a sudden reduction in cardiac output, when emergency trans-esophageal echocardiography revealed right heart failure with thrombus formation in the right atrium and right ventricle (Figure 1 C Video 1, and Video 2). A patent foramen ovale was excluded.
The patient was urgently transferred to the operating theater for pulmonary embolectomy and additionally to establish salvage veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for fulminant right heart failure. At surgery, multiple formations of pulmonary thrombi were retrieved (Figure 1 D). The following day, re-thoracotomy was necessary for evacuation of a mediastinal hematoma, as well as to upgrade from VA-ECMO to veno-arterial-venous ECMO (VAV-ECMO) due to ongoing respiratory failure despite VA-ECMO therapy. The patient also developed arterial embolism affecting his left hand, which was treated conservatively in view of adequate anticoagulation with unfractionated heparin whilst receiving mechanical circulatory support (MCS), and on account of his complex hemodynamic instability. On the second post-operative day, continuous veno-venous hemodialysis was commenced for acute kidney injury.
The arterial ECMO cannula was removed one week after the initial surgery, following recovery of right heart function, and veno-venous ECMO (VV-ECMO) was maintained for another 10 days. An improvement of lung function and neurological status during VV-ECMO and prone ventilator therapy were observed. The patient was subsequently extubated and three weeks after initial surgery he was discharged to a rehabilitation unit with right-sided hemiparesis and leg weakness. During his intensive care unit stay, a comprehensive haematology screen did not yield evidence of any underlying hypercoagulable disorder.