Pulmonary embolism and COVID-19

Abstract

Since December 2019, the severe acute respiratory syndrome coronavirus (SARS-CoV-2) outbreak has reached pandemic proportion and has become a public health crisis of unprecedented magnitude. Although coronavirus disease-2019(COVID-19) primarily targets the respiratory system, the cardiovascular system can also be affected in a significant percentage among the patients. Cardiac injuries appear to be a prominent feature of the COVID-19 infection as they occur in 20-30% of the hospitalized patients and are often responsible for deadly outcome. Pulmonary vascular complications such as pulmonary embolism are frequently present, with higher prevalence in COVID-19 than usually encountered in critically ill patients who do not suffer from infection. Moreover, there is a rising evidence that traditional risk factors for PE are not commonly encountered among the patients with COVID-19 infection but rather independent biological and clinical findings, with the inflammation as a main contributor of thromboembolism. The endothelial dysfunction, abnormal hemostasis, severe lung inflammation and disseminated intravascular coagulation play a central role in the predisposition to venous thromboembolic events. Integrated approach of heart and lung multimodality imaging has a crucial role in different clinical scenarios and is of great importance in the diagnosis, management, risk stratification and prognosis of patients with COVID-19, providing a base for further clinical decision making. Routine history, physical examination, laboratory testing, electrocardiography, and plain x-ray imaging may offer the required information in some of the cases but the overlap between COVID-19 and typical cardiovascular diagnoses such as acute myocardial infarction, heart failure and acute pulmonary embolism, mandate advanced imaging techniques to assist in differential diagnosis and treatment. Baseline CT is the most used tool to confirm diagnosis and to give information about the disease extent and severity, but it is also a reference for subsequent imaging follow-up. According to some studies, the sensitivity of chest CT for COVID-19 was 97%. In the clinical scenario of a patient with COVID-19, who has just undergone CT of the lungs but the findings cannot explain the severity of respiratory failure, CT pulmonary angiography should be considered to exclude/confirm pulmonary embolism. We hereby report a case of 72y/old patient who was admitted at our clinic ( which is not a Covid-center) with severe chest pain and signs of hemodynamic instability. His ECG revealed a heart rate of 125/min , right axis deviation and S1Q3T3 pattern. Bedside echo showed severely dilated RV with reduced systolic function and features of pulmonary hypertension. His laboratory findings were consistent with leukocytosis with lymphopenia, elevated CRP, extremely elevated D-dimers and high troponin. Anticoagulation was immediately initiated by using UFH. The patient was referred to CT angiography and it revealed bilateral filling defects in the main pulmonary arteries. Bilateral peripheral ground-glass opacities and small areas of consolidation were also present which raised the suspicion of COVID-19 infection. The swab for SAS-COV-2 was positive. The patient underwent systemic fibrinolysis with full-dose alteplase, with rapid hemodynamic and respiratory success. His further treatment included therapeutic dose of LMWH, parenteral antibiotic and gastroprotective treatment. The repeated echocardiographic exam showed a clear improvement of the hemodynamics of the RV, a reduction of RV dilatation and of pulmonary pressures and reduction of vena cava diameter. The patient was transferred for further treatment at the COVID department and was discharged 2 weeks later after his full recovery and was advised to continue with oral anticoagulant therapy and to use Rivaroxaban 15mg twice daily for 3 weeks and afterwards 20mg once daily. Conclusion: PTE is frequently observed among COVID-19 patients and this complication can happen in the absence of major predisposing factors. COVID-19 pneumonia seems to confirm the impact of severe respiratory infection as a precipitant factor for acute venous thrombo-embolism and the causal relationship. Multimodality imaging in COVID-19 patients with suspected cardiac involvement by using POCUS, chest CT and pulmonary angiography is of crucial importance for rapid differential diagnosis and treatment especially in patients with hemodynamic instability. The use of systemic thrombolysis in haemodynamically unstable patients is the first and more appropriate therapeutic strategy, considering the current guidelines recommendations for management of acute PE. However, thrombocytopenia occurs in a non-neglectable proportion of patients with COVID-19 infection and is an independent predictor of increased mortality in these patients. The reperfusion strategy of COVID-19 patients must be tailored according to the severity of thrombocytopenia where catheter directed treatment might be potential first line therapeutic approach.