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\begin{document}

\title{Collateral Damage of COVID-19 Pandemic: Delayed Medical Care}



\author[1]{Saqib Masroor}%
\affil[1]{University of Toledo Medical Center}%


\vspace{-1em}



  
  \date{March 14, 2025}


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\selectlanguage{english}
\begin{abstract}
During the COVID-19 pandemic, ER visits have drastically decreased for
non-COVID conditions such as appendicitis, heart attack and stroke.
Patients may be avoiding seeking medical attention for fear of catching
the deadly condition or as an unintended consequence of stay-at-home
orders. This delay in seeking care can lead to increased morbidity and
mortality, which has not been figured in the assessment of the extent of
damage caused by this pandemic. This case illustrates an example of
``collateral damage'' caused by COVID-19 pandemic. What would have been
a standard STEMI treated with timely and successful stenting of a
dominant right coronary artery occlusion, became a much more dangerous
post-infarction VSD; all because of a 2-day delay in seeking medical
attention by an unsuspecting patient.%
\end{abstract}%



\sloppy


Collateral Damage of COVID-19 Pandemic: Delayed Medical Care

Saqib Masroor, MD, MHS

University of Toledo College of Medicine and Life Sciences

Heart and Vascular Center

3000 Arlington Avenue

Toledo, OH 43614

Email: saqib.masroor@utoledo.edu

Keywords: COVID-19, Coronary artery disease, Post infarction ventricular
septal defect

Short title: ``Collateral Damage of COVID-19''

ABSTRACT:

During the COVID-19 pandemic, ER visits have drastically decreased for
non-COVID conditions such as appendicitis, heart attack and stroke.
Patients may be avoiding seeking medical attention for fear of catching
the deadly condition or as an unintended consequence of stay-at-home
orders. This delay in seeking care can lead to increased morbidity and
mortality, which has not been figured in the assessment of the extent of
damage caused by this pandemic. This case illustrates an example of
``collateral damage'' caused by COVID-19 pandemic. What would have been
a standard STEMI treated with timely and successful stenting of a
dominant right coronary artery occlusion, became a much more dangerous
post-infarction VSD; all because of a 2-day delay in seeking medical
attention by an unsuspecting patient.

CASE REPORT:

A 48 year old male presented to the emergency room (ER) with a 2-day
history of persistent chest pain. EKG revealed an ST-elevation
myocardial infarction (STEMI) in the inferolateral distribution. Per the
ACC guidelines, patient underwent a timely and successful percutaneous
revascularization of the dominant right coronary artery that was
occluded. The left coronary circulation did not have significant
disease. A large amount of clot was also removed from the artery during
the procedure in which two drug eluting stents were deployed in the mid
to distal right coronary artery.

Overnight the patient's condition worsened as he developed cardiogenic
shock with tachycardia, hypotension and a loud holo-sytolic murmur was
noted. His chest x-ray revealed worsening pulmonary congestion. A stat
echocardiogram revealed a large ventricular septal defect (VSD) (Fig 1)
and the patient was taken back to the catheterization laboratory for
right heart catheterization and placement of intra-aortic balloon pump
(IABP). The final diagnosis was a postinfarction VSD measuring 2 cm in
dimension and a shunt fraction of 3. Since the patient's hemodynamics
improved with the IABP, we waited a few days to let the myocardium heal
somewhat before surgical repair. He also tested negative for COVID-19.

Five days after his hospital presentation, and 7 days after his chest
pain started, he was taken to the operating room, where a large 3 cm VSD
was repaired using the exclusion technique with pericardial patch.
Except for the upper two 1-1.5 cm, the rest of the septum could not hold
any stitches and therefore the pericardial patch was subtended through
the anterior wall of the left ventricle, parallel to the left anterior
descending artery (interrupted horizontal mattress sutures tied outside
the heart on pledgets), through the inferior ventriculotomy (sandwiched
between the two layers of muscle closure) and moving up along the
lateral wall adjacent to the septolateral junction and extending up to
the origin of the anterolateral papillary muscle (Interrupted horizontal
mattress sutures tied outside the heart over a pledget). The LAA was
excluded with an epicardial clip and epicardial bipolar leads were
placed on the lateral wall of left ventricle and the right atrium. The
origin of the anterolateral papillary muscle was reinforced with a
pledgeted stitch through and through the ventricular wall.
Intraoperative TEE showed a competent repair with trace residual
shunting (Fig 2). The IABP was removed on postoperative day 1 and he was
extubated and weaned off inotropes on the second postoperative day. He
is still in hospital, but we hope he will continue to make adequate
recovery.

On a separate but very important note, in keeping with the policy of
``No Visitation'' to prevent spread of COVID-19, his wife and family
have not seen him since his admission to the hospital, although they did
speak to him by phone before surgery and continue to do so now, that he
is extubated.

\emph{Discussion:}

This case highlights the issues that have been raised before by others
regarding the corona virus, stay-at-home regulations and demand for
emergency care for non-COVID conditions. A recent article published in
the Washington Post (1), has reported that physicians in the United
States, Spain and UK have all noticed a serious decline in the number of
patients coming to the ER not only for typical problems like
appendicitis, bowel obstructions, gall bladder problems but also for the
more critical heart attacks and strokes. Metzler reports a 40\% decline
in the number of admissions for STEMI and non-STEMI in Austria during
the COVID-19 pandemic (2). In a soon to be published report by Garcia
(3), number of cardiac catheterization laboratory activations for STEMI
have been reduced by almost 40\% in 9 high volume centers in the United
States.

The reasons for this decline are many and include a fear for catching a
deadly virus in the hospital, the instruction to strictly stay in-house,
consideration of many heart related symptoms of shortness of breath and
chest discomfort by patients to be related to respiratory infections and
best dealt with at home etc.

This patient's pain started two days earlier, but he did not seek
attention until later. From conversation with him and his wife, they
were concerned about the risk of catching the deadly COVID-19 in the
hospital. The patient was not a smoker or a known diabetic, and did not
have any family history of coronary artery disease. A heart attack was
not on their mind but respiratory infection and fear of COVID-19 was the
first and foremost concern of theirs. It was not until his chest pain
had persisted for two days that he finally came to ER. Had he come when
the pain had started, this patient would likely have had an uneventful
recovery after treatment of the RCA occlusion per the ACC guidelines.
His avoidance of an ER visit in a timely fashion because of the fear of
COVID-19, led to the catastrophic complication of STEMI that surgeons
rarely see today because of successful results of timely percutaneous
revascularization.

Whatever the reason for this patient's or that of others to delay
seeking medical attention during this pandemic, the concern remains that
this delay will lead to increased morbidity and mortality in the coming
weeks and months. There most certainly are many others like this
patient, who have suffered or will suffer a catastrophic complication
due to delay in treatment. Metzler posits that if 40\% of people are not
seeking care for acute coronary syndromes, and assuming 40\% of those
untreated people suffer a significant complication or death (2), the
effect of COVID-19 pandemic on non-COVID related health of our
population may be even more devastating than COVID-19 itself. And this
case just highlights the fact that this assumption may not be too far
from the truth.

REFERENCES.

\begin{enumerate}
\tightlist
\item
  Bernstein, L. and Sellers FS. (2020) Patients with heart attacks,
  strokes and even appendicitis vanish from hsoptals. \emph{Washington
  Post.} April 19, 2020.
  https://www.washingtonpost.com/health/patients-with-heart-attacks-strokes-and-even-appendicitis-vanish-from-hospitals/2020/04/19/9ca3ef24-7eb4-11ea-9040-68981f488eed\_story.html
\item
  Metzler B, Siostrzonek P, Binder RK, Bauer A and Reinstadler SJ.
  (2020) Decline of acute coronary syndrome admissions in Austria since
  the outbreak of COVID-19: the pandemic response causes cardiac
  collateral damage. \emph{Eur Heart J} 0, 1-2.
  Doi:10.1093/eurheartj/ehaa314
\item
  Garcia S, Albaghdadi MS, Meraj PM, et al. (2020) Reduction in
  ST-segment elevation cardiac catheterization laboratory activations in
  the United States during COVID-19 pandemic. \emph{J Amer Coll
  Cardiol,} https://doi.org/10.1016/j.jacc.2020.04.011
\end{enumerate}

\textbf{Fig 1}\selectlanguage{english}
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\textbf{Fig 2.}\selectlanguage{english}
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\textbf{Figure Legend}

\textbf{FIG 1.} Transthoracic echocardiography revealing a large VSD
(white arrow) extending form mid septum to the apex.

\textbf{Fig 2.} Intraoperative post-repair transesophageal
echocardiography demonstrating a competent repair of the VSD.\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/Fig-1b/Fig-1b}

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\includegraphics[width=0.70\columnwidth]{figures/Fig-2/Fig-2}

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