COVID-19 Hypercoagulability Can Manifest as Right Ventricular Clot in Transit

By Reuters Staff

June 09, 2020

NEW YORK (Reuters Health) - COVID-19-associated hypercoagulability can manifest as a right ventricular clot in transit, according to a case report.

Dr. Samjum S. Sethi and colleagues from Columbia University Irving Medical Center and New York Presbyterian Hospital, in New York City, present a case of right ventricular thrombus in a patient with COVID-19 and discuss the challenges in the workup and treatment of COVID-19 patients in their online report in JACC: Case Reports.

The 44-year-old man was admitted following two days of shortness of breath and nonproductive cough. He was hypoxic, with a peripheral oxygenation saturation of 86% while breathing 6 L per minute of supplemental oxygen via nasal cannula with an additional 15 L per minute applied by non-rebreather mask.

Following intubation, his arterial blood gas improved slightly, but the results, along with chest x-ray findings of diffuse bilateral hazy opacities, were consistent with moderate acute respiratory distress syndrome (ARDS).

His D-dimer level was greater than the upper limit of detection, and he remained hemodynamically unstable and severely hypoxic, which together prompted transthoracic echocardiography (TTE). TTE showed global hypokinesis (with a left ventricular ejection fraction of 45%) and a moderately to severely dilated right ventricle with moderately to severely reduced right ventricular systolic function.

There was also a well circumscribed mobile echodensity attached to the right ventricular free wall which was concerning for clot in transit.

The pulmonary embolism response team (PERT) was consulted, and the patient was treated with tissue-type plasminogen activator (tPA) and systemic anticoagulation with unfractionated heparin once the tPA infusion was complete.

He was subsequently weaned off pressors and inotropic support, and his repeat TTE showed normal left ventricular systolic function, mild dilation of the right ventricle with preserved right ventricular systolic function, and resolution of the previously seen clot in transit.

The patient remained hospitalized but off of vasoactive medication and was making progress toward extubation followed by continued oral anticoagulation for at least three to six months after hospital discharge.

Based on the experience with this patient, the authors propose an algorithm that outlines their approach for testing and treatment for venous thromboembolism in the setting of COVID-19.

That algorithm begins with heightened suspicion for pulmonary embolism (PE) in symptomatic patients with COVID-19. Hemodynamically unstable patients with a new vasopressor requirement should undergo TTE and/or chest CT angiography (CTA), and patients at high risk of PE should receive systematic fibrinolysis.

Hemodynamically stable patients should undergo TTE, and those with right ventricular strain who remain hemodynamically stable can proceed to CTA. Those deemed at intermediate risk of PE should begin anticoagulation unless contraindicated.

In the absence of right ventricular strain, patients should be evaluated for deep vein thrombosis (DVT). Those with DVT can receive therapeutic anticoagulation and those without DVT or PE can continue DVT prophylaxis.

"COVID-19 appears to be associated with an increased propensity for thromboembolic disease," the authors conclude. "Heightened suspicion is necessary to clinically detect venous thromboembolism in this disease and treat accordingly, while mindful of the inherent risks to healthcare workers and resources available, depending on the level of crisis, in the overall health system."

Dr. Sethi did not respond to a request for comments.

SOURCE: JACC: Case Reports, online May 29, 2020.


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