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.