3. DISCUSSION
Thromboembolic complications are reported in 27% of COVID-19 patients [1] with challenging diagnosis due to similarity of its clinical manifestations and laboratory findings with the usual features of COVID-19 infection. Thus, high index of clinical suspicion is recommended in addition to emergency pulmonary angiography or echocardiography in supected patients [4]. Our report describes a rare case of large TVT in COVID-19 female patient during the third wave of the pandmic. One previous report described a large thrombus-in-transit through the tricuspid valve into the RV in adult male [2], and another report described a large TVT extended to the RA and RV and attached to the tip of central venous catheter in a child [3].
Our patient had unremarkable risk factors for thrombosis prior to COVID-19 infection. The clinical, laboratory, and imaging workups to distinguish thrombotic disease from COVID-19 infection are challenging due to: 1) similar presentation of dyspnea, chest pain, tachypnea, and tachycardia in patients with thrombosis or COVID-19; 2) routine use of prophylactic anticoagulants in all COVID-19 patients; 3) usual elevation of D-dimer and pro-inflammatory markers in both conditions; and 4) limited mobility of COVID-19 patients which may delay the proper imaging study to identify thrombotic diseases.
In our case, TVT was initialy detected on bedside TTE; however, TTE could not differentiate thrombus from vegetation thus CMR was performed for further evaluation. CMR has the ability to detrmine the acuity of a thrombus and to differentiate it from cardiac tumors or other true cardiac lesions [5]. Moreover, CMR has a specific role in COVID-19 patients to determine cardiovascular complications because of its high accuracy in evaluation of myocardial structure, function, tissue characterisation, and perfusion [6].
The decision for surgery in our case aimed to avoid subsequent complications of a large mobile thrombus (> 2 cm) associated with moderate-to-severe TR. The treatment of TVT includes medical therapy with anticoagulants or fibrinolytics, surgery, and percutaneous directed retrieval. Each modality has its benefits and risks [7]. Therefore, the treatment should be decided on indvidual basis depending on size and dynamics of the thrombus, surgical fittness, ventricular function, and hemodynamic stability [3, 8].