DISCUSSION
Whether the initial surge in COVID-19 patients has subsided and hospitals expand their operative caseloads or there is a subsequent increase in COVID-19 cases, there will inevitably be some degree of COVID transmission within healthcare setting and community. Surgeons should be cognizant of the prevalence of COVID-19 in their community and institution, and include it in their differential should postoperative complications arise.3,4,5 In our case report, the patient recovered from an uncomplicated CABG but experienced severe sequelae of COVID-19 disease.
On presentation to the emergency department, the patient was found to have a STEMI. Given his high risk of exposure to COVID-19 and absence of chest pain at the peak of the pandemic he was treated medically. Other stricken localities have experienced similar decision making processes.6
The patient was found to have elevated d-dimers, a marker of a hypercoagulable state, which is consistent with reports of severe hypercoagulability seen in COVID-19.7,8 While there have been reports of patients contracting COVID-19 after undergoing CABG, our case demonstrates the first report of thrombotic complications due to COVID-19 in a patient after CABG.4
Our patient’s hypercoagulable state may have predisposed him to graft thrombosis leading to a STEMI. Other causes of STEMI have been reported in patients with COVID-19 including direct viral entry through the angiotensin-converting enzyme 2 receptor leading to cellular toxicity, hypoxic related myocyte injury and immune-mediated cytokine storm.9 His presentation with a STEMI is likely to be multifactorial, however without a catheterization we are unable to confirm if this was due to graft/native vessel thrombosis or direct myocyte injury.
Our patient’s hospital course was complicated by other events that may be attributed to the hypercoagulable state associated with COVID-19. He experienced an acute embolic stroke with residual left hemiparesis and blues toes thought to be due to microthrombi. The events occurred despite being fully anticoagulated with heparin. Possible sources of the emboli are the brief episode of atrial fibrillation or the formation of thrombi in the hypokinetic left ventricle in combination with hypercoagulable diathesis.
As hospitals begin to transition back to an increased operative case load, surgeons will have to be aware of both community and hospital acquired COVID-19 infection. In addition, they should be cognizant of the potential thrombotic sequelae of COVID-19 in patients undergoing CABG. With relation to cardiac surgery outcome and quality reporting, COVID-19 may affect publicly reported patient outcomes and may require new risk adjustments.