Case report:
A 40 years old woman presented at the emergency department because of
progressive dyspnea, orthopnea, edema, weakness. She has involved with
COVID-19 about 2 months ago according to polymerase chain reaction (PCR)
and chest computed tomography (CT), But she didn’t recover from
respiratory symptoms in spite of adequate treatment. In admission time,
she has respiratory distress, tachycardia, tachypnea, edema, cyanosis
and coldness of extremely and systemic hypotension (Blood Pressure:
90/65 mmHg). O2 saturation in air room was 86% and with noninvasive O2
therapy increased to 89%.
Electrocardiogram (ECG) showed sinus tachycardia, right axes deviation
and right ventricle (RV) strain pattern in precordial leads (Figure 1).
Chest X ray showed significant cardiomegaly, RV enlargement and
prominent main of PA and left PA without evidence of pulmonary venous
congestion (Figure 2). Spiral chest CT demonstrated evidence of previous
COVID-19 involvement with ground glass appearance and air trapping in
both lungs and also cardiomegaly and large size pericardial effusion
(Figure 3).
Transthoracic echocardiography (TTE) showed severe RV enlargement with
severe RV systolic dysfunction, right atrial (RA) enlargement and
abnormal interventricular septal motion. D shaped appearance of
Interventricular septum in parasternal short axis (PSAX) view with mid
systolic flattening, representing severe RV pressure overload and signs
of severely increased RV afterload pattern. In PSAX view, very large
size nonhomogeneous solid mobile mass is seen in distal right
ventricular outflow tract (RVOT) extended to main PA and has attachment
to pulmonary valve (PV). The PV obstruction was severe and blood flow to
main PA was reduced. Left and right PA and pulmonary bifurcation were
evaluated, that were spared without any mass. Color doppler study of
tricuspid valve (TV) inflow showed severe tricuspid regurgitation (TR)
and hemodynamic study with continuous doppler wave in apical 4 chamber
view demonstrated TR peak velocity of 4.4 m/s (TR peak gradient: 77
mmHg). Evaluation of inferior vena cava (IVC) in subcostal view was
done. IVC was severely enlarged (2/75 cm diameter) without respiratory
collapse. Therefore, hemodynamic study estimated RA pressure about 20
mmHg, more compatible with chronic course of disease and indicating of
more gradual increasing of RV pressure rather than acute event. Massive
pericardial effusion was seen more localized in posterolateral of left
ventricle (LV) (maximum diameter: more than 3 cm). There was significant
respiratory variation in Doppler study of mitral valve (MV) and TV
diastolic inflow velocity more than 30% (Figure 4).
Laboratory data containing hematologic, inflammatory and biomarkers were
measured. D dimer was increased about 4000 μg/l and pro-brain
natriuretic peptide (pro-BNP) 12500 ng/d.
According to previous history of the COVID-19, ECG manifestation,
echocardiography, chest X ray, spiral chest CT, laboratory data and
abnormal hemodynamic condition, massive sub-acute PTE was highly
suggested. Due to our patient hemodynamic disturbance, massive
pericardial effusion and giant mass, emergent cardiac consultation with
cardiovascular surgical team for surgical resection was done and the
patient was taken to operating room.
Thoracotomy and median sternotomy was done and then cardiopulmonary
bypass was established. Main PA was incised. Unexpectedly, out of
previous suspicious, our surgeon encountered with large size tumoral
solid mass with firm texture that was attached to right leaflet of PV
and protruded to main PA and RVOT, which appearance was highly
suggestive for sarcoma rather thrombosis. Therefore, mass completely was
resected and because of tumoral involvement, right leaflet of PV removed
(Figure 5). Reevaluation for residual masses in other parts was done
with intraoperative echocardiography. TEE confirmed there was not any
other masses in PA. Severe pulmonary insufficiency (PI) was seen after
removal of right leaflet of PV. Staged operation for reconstruction of
RVOT with conduit PV was postponed after preparing the result of tumor
pathology and probably need for adjuvant chemotherapy. Patient had
stable hemodynamic in ICU, intubated easily and discharged after 7 days
without any cardiac event.
Pre-discharge TTE was done. RV and RA were severely enlarged. RV
systolic function was severely impaired and severe TR and severe PI was
seen. No residual mass was seen in RVOT, PV, PA and main of PA.
Continuous doppler wave study showed peak TR velocity 4 m/s and short
pressure half time (PHT:24 ms) and in 2D study evidence of increased RV
after load pattern was permanent. IVC plethora and engorgement without
respiratory collapse was seen (Figure 6).
Pre-discharge pulmonary CT angiography was done that any mass or
thrombus in pulmonary vasculature wasn’t seen. In addition,
abdominopelvic and brain CT for further evaluation were performed which
were not abnormal.