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A case report of a large intracardiac thrombus in a COVID-19 patient managed with percutaneous thrombectomy and right ventricular mechanical circulatory support

ABSTRACT: Abstract

Background

The coronavirus disease 2019 (COVID-19) has caused a global pandemic with an unprecedented burden on health and the economy worldwide. Although it primarily involves the respiratory tract system, cardiovascular complications, particularly arterial and venous thrombosis, are frequently reported and are associated with adverse outcomes.

Case summary

We describe the case of a 57-year-old female who presented with acute hypoxic respiratory failure and shock. She was found to have left lower extremity deep vein thrombosis and a suspected pulmonary embolism. A large mobile right atrial mass was found on echocardiogram. Given the large thrombus burden that portended an extremely high risk for embolization to the pulmonary arteries, emergent percutaneous aspiration of an organized thrombus (rather than thrombolysis) was performed using the AngioVac system (Angiodynamics Inc., Latham, NY, USA) complicated by haemodynamic collapse due to acute right ventricular failure. An Impella RP (Abiomed, Danvers, MA, USA) was then placed, with rapid stabilization of haemodynamics. The patient tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). She was treated with antimicrobial and systemic anticoagulation therapy. She was successfully weaned off the Impella RP on post-operative day 4 and was extubated on day 5. She was discharged on day 16 in a stable condition.

Discussion

Incident venous thrombo-embolism is frequently encountered in COVID-19 patients. We report the first case of a large intracardiac thrombus associated with SARS-CoV-2 infection managed successfully with percutaneous thrombectomy and right ventricular mechanical circulatory support.

SUBMITTER: Kaki A

PROVIDER: S-EPMC7665472 | biostudies-literature | 2020 Nov

REPOSITORIES: biostudies-literature

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Project description:OBJECTIVES:To review temporary percutaneous mechanical circulatory support devices for the treatment of cardiogenic shock, including current evidence, contraindications, complications, and future directions. DATA SOURCES:A MEDLINE search was conducted with MeSH terms: cardiogenic shock, percutaneous mechanical circulatory support, extracorporeal membrane oxygenation, Impella, and TandemHeart. STUDY SELECTION:Selected publications included randomized controlled trial data and observational studies describing experience with percutaneous mechanical circulatory support in cardiogenic shock. DATA EXTRACTION:Studies were chosen based on strength of association with and relevance to cardiogenic shock. DATA SYNTHESIS:Until recently, there were few options if cardiogenic shock was refractory to vasopressors or intra-aortic balloon pump counterpulsation. Now, several percutaneous mechanical circulatory support devices, including Impella (Abiomed, Danvers, MA), TandemHeart (CardiacAssist, Pittsburgh, PA), and extracorporeal membrane oxygenation, are more accessible. Compared with intra-aortic balloon pump, Impella provides greater hemodynamic support but no reduction in mortality. Similarly, TandemHeart improves hemodynamic variables but not survival. Comparative studies have been underpowered for mortality because of small sample size. Veno-arterial extracorporeal membrane oxygenation offers the advantage of biventricular circulatory support and oxygenation, but there are significant vascular complications. Comparative studies with extracorporeal membrane oxygenation have not been completed. Despite lack of randomized controlled data, there has been a substantial increase in use of percutaneous mechanical circulatory support. Several ongoing prospective studies with larger sample sizes may provide answers, and newer devices may become smaller, easier to insert, and more effective. CONCLUSIONS:Mortality from cardiogenic shock remains unacceptably high despite early coronary revascularization or other therapies. Although evidence is lacking and complications rates are high, improvements and experience with percutaneous mechanical circulatory support may offer the prospect of better outcomes.

Project description:BackgroundPercutaneous mechanical circulatory support devices (pMCSDs) are increasingly used on the assumption (but without solid proof) that their use will improve prognosis. A meta-analysis was undertaken according to the PRISMA guidelines to evaluate the benefits of pMCSDs in patients undergoing high-risk percutaneous coronary intervention (hr-PCI).MethodsWe searched PubMed, EMbase, Cochrane Library, Clinical Trial.gov, and other databases to identify eligible studies. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated for 30-day and 6-month all-cause mortality rates, reinfarction, and other adverse events using a random effect model.ResultsSixteen randomized controlled trials (RCTs) were included in this study. In the pooled analysis, intra-aortic balloon pump (IABP) was not associated with a decrease in 30-day and 6-month all-cause mortality (RR 1.01 95% CI 0.61-1.66; RR 0.88 95% CI 0.66-1.17), reinfarction (RR 0.89 95% CI 0.69-1.14), stroke/transient ischemic attack (TIA) (RR 1.75 95% CI 0.47-6.42), heart failure (HF) (RR 0.54 95% CI 0.11-2.66), repeat revascularization (RR 0.73 95% CI 0.25-2.10), embolization (RR 3.00 95% CI 0.13-71.61), or arrhythmia (RR 2.81 95% CI 0.30-26.11). Compared with IABP, left ventricular assist devices (LVADs) were not associated with a decrease in 30-day and 6-month all-cause mortality (RR 0.96 95% CI 0.71-1.29; RR 1.23 95% CI 0.88-1.72), reinfarction (RR 0.98 95% CI 0.68-1.42), stroke/TIA (RR 0.45 95% CI 0.1-1.95), acute kidney injury (AKI) (RR 0.83 95% CI 0.38-1.80), or arrhythmia (RR 1.52 95% CI 0.71-3.27), but LVADs were associated with a decrease in repeat revascularization (RR 0.26 95% CI 0.08-0.83). However, LVADs significantly increased the risk of bleeding compared with IABP (RR 2.85 95% CI 1.72-4.73).ConclusionsNeither LVADs nor IABP improves short or long-term survival in hr-PCI patients. LVADs are more likely to reduce repeat revascularization after PCI, but to increase the risk of bleeding events than IABP.