Case Report
A 33-year old man without any known comorbidities presented with
dyspnoea to our tertiary center. He tested positive for COVID-19 two
weeks prior to admission during a business trip in Asia. With
progressive deterioration in his lung function, he was intubated and
mechanically ventilated in a prone position in accordance with
guidelines for the management of Acute Respiratory Distress Syndrome
(ARDS). Brain and thoracic computed tomography (CT) scanning were
performed to investigate a persistent neurological deficit following
sedation withdrawal, and demonstrated a large left-sided ischemic stroke
(Figure 1 A) with extensive central pulmonary embolism (Figure 1 B). The
patient subsequently developed a sudden reduction in cardiac output,
when emergency trans-esophageal echocardiography revealed right heart
failure with thrombus formation in the right atrium and right ventricle
(Figure 1 C Video 1, and Video 2). A patent foramen ovale was excluded.
The patient was urgently transferred to the operating theater for
pulmonary embolectomy and additionally to establish salvage
veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for
fulminant right heart failure. At surgery, multiple formations of
pulmonary thrombi were retrieved (Figure 1 D). The following day,
re-thoracotomy was necessary for evacuation of a mediastinal hematoma,
as well as to upgrade from VA-ECMO to veno-arterial-venous ECMO
(VAV-ECMO) due to ongoing respiratory failure despite VA-ECMO therapy.
The patient also developed arterial embolism affecting his left hand,
which was treated conservatively in view of adequate anticoagulation
with unfractionated heparin whilst receiving mechanical circulatory
support (MCS), and on account of his complex hemodynamic instability. On
the second post-operative day, continuous veno-venous hemodialysis was
commenced for acute kidney injury.
The arterial ECMO cannula was removed one week after the initial
surgery, following recovery of right heart function, and veno-venous
ECMO (VV-ECMO) was maintained for another 10 days. An improvement of
lung function and neurological status during VV-ECMO and prone
ventilator therapy were observed. The patient was subsequently extubated
and three weeks after initial surgery he was discharged to a
rehabilitation unit with right-sided hemiparesis and leg weakness.
During his intensive care unit stay, a comprehensive haematology screen
did not yield evidence of any underlying hypercoagulable disorder.