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.