key: cord-256075-fudeaq7y
authors: Audo, Andrea; Bonato, Valeria; Cavozza, Corrado; Maj, Giulia; Pistis, Gianfranco; Secco, Gioel Gabrio
title: Acute Pulmonary Embolism in SARS-CoV-2 Infection Treated with Surgical Embolectomy
date: 2020-04-28
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2020.04.013
sha: 
doc_id: 256075
cord_uid: fudeaq7y

Abstract A cluster of pneumonia cases caused by the novel SARS-CoV-2 has spread rapidly throughout China, Europe and USA. The pneumonia might evolve in ARDS requiring assisted mechanical-ventilation. The prolonged immobilization combined with respiratory failure, sepsis and dehydration might expose SARS-CoV-2/patients to increased risk of complication including pulmonary embolism. We report the first case of SARS-CoV-2 complicated by massive pulmonary embolism underwent successfully surgical embolectomy. We believe that maintaining the same pro-active attitude suggested by current Guidelines might help in reducing morality and improving survival in SARS-COV-2/patients.

In late December 2019, a cluster of pneumonia cases caused by a novel coronavirus named SARS-CoV-2 occurred in Wuhan, China and spread rapidly throughout Europe with Italy as the third country with most confirmed cases (1, 2) . SARS-CoV-2 infected patients usually experience fever, dry cough, fatigue and worsening dyspnoea with interstitial pneumonia that in up to 3-5% might unfortunately evolve in a severe acute respiratory distress syndrome (ARDS) requiring endotracheal intubation (ETI) and mechanical ventilation.

We report a case of a 59 years old Caucasian male with no evidence of cardiovascular risk factor and no medical therapy before hospitalization. He was admitted with a 10days history of fever and dyspnoea unresponsive to paracetamol. Physical examination revealed a tachycardic hear rate (112 beats/minute), low blood pressure (90/50mmHg) and severe hypoxemia. Serial 12-leads electrocardiogram showed sinus tachycardia without ST segment elevation/depression or other electric pathways suggesting myocardial sufferance; chest x-ray showed signs of severe interstitial pneumonia with typical ground-glass changes suggesting SARS-CoV-2 infection ( Figure 1 ).

Echocardiography was within normal limits. Due to the severe ARDS unresponsive to assisted non-invasive ventilation the patient underwent ETI and was transferred to an isolation ward of the intensive care unit (ICU); the infection of SARS-CoV-2 virus was confirmed thereafter by an RT-PCR assay of a nasal swab. After few days of mechanical ventilation, the patient suddenly developed a cardiac arrest followed, after resuscitation, by acute hemodynamic deterioration. Urgent echocardiography showed a severe dysfunction of the right cardiac chambers highly suggestive for acute pulmonary embolism (PE). Due to rapid deterioration of the hemodynamic condition a CT-scan was not performed, and he was immediately transferred to our cardiac surgery room. Moreover, the need for isolation in dedicated COVID-positive units or hospitals may limit access to examinations such as ECG, echocardiography or CT-scan and hemodynamic instability can be dismissed because of the widespread viral organ involvement (3, 4) .

Even when there is a clear diagnosis, there might be reluctance to apply in this subset of patients the aggressive standard approach recommended by Guidelines (5) . Current management of significant PE is focused in reducing clot size through systemic/catheter directed thrombolysis or removing the clot entirely with percutaneous suction or surgical embolectomy (6) . The American Heart Association (AHA) and European Society of Cardiology (ESC) suggest surgical embolectomy in case of hemodynamic instability or failed/ contraindications to thrombolysis, patent foramen ovale, thrombus in transit in the right sided cardiac chambers and also patient that are predicted to die before realizing the benefits of thrombolytics (7) . In our patient the rapid progressive hemodynamic deterioration forced us to an urgent surgical approach aimed to achieve complete clots removal. A systemic thrombolysis could have been certainly easier, but we believe that in such unstable condition was unlikely to offer the same effective and prompt hemodynamic improvement.

We are now facing this unexpected severe SARS-CoV-2 pandemic, but maintaining the same proactive attitude suggested by current Guidelines or routine standard of care might help in reducing morality rate and improving survival also in SARS-CoV-2 infected patients.

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