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      Large intracardiac thrombus in a COVID-19 patient treated with prolonged extracorporeal membrane oxygenation implantation

      case-report
      e1 , e2 , e3 , e4 , e5
      European Heart Journal
      Oxford University Press

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          Abstract

          We report a COVID-19 case with the longest ECMO before lung transplantation. It is also the first reported case with severe intracardiac thrombus complication of the SARS-CoV-2 infection. A 53-year-old previously healthy Chinese man presented with muscle soreness, dry cough, and fever for 5 days. Computed tomography (CT) confirmed diffuse ground-glass infiltrates of both lungs (Panel A). Nucleic acid test was positive for COVID-19 infection. His condition rapidly deteriorated in spite of prompt antivirus, anti-inflammatory, immunoenhancer, glucocorticoid, and supportive therapies. Soon he produced more purulent secretions, and developed acute respiratory distress syndrome, metabolic acidosis, septic shock, and multiple organ failure. He was intubated, and extracorporeal membrane oxygenation (ECMO, V-V mode) was started. A subsequent CT indicated large-sized heterogeneous high-density shadows with incomplete expansion in both lungs, and pleural effusion (Panel B). X-ray displayed a typical ‘white lung’ sign, without a clear border of the heart and mediastinum (Panel C). On day 34 after ECMO was initiated, an echocardiogram revealed a mobile, linear, and large-sized (3.3 × 0.6 cm) echogenic mass in the right atrium, attached to the tip of the ECMO catheter (Panel D). The right ventricular outflow tract (RVOT) became widened, pulmonary artery pressure was significantly increased, and left ventricular diastolic function was markedly decreased. Anticoagulation therapy was started immediately, and adjusted based on frequently monitored clotting function (Supplementary material online, Figure 1). Ten days later, thrombus was no longer detected throughout the heart or large vessels. After three transfusions of serum from COVID-19 survivors, his nucleic acid test was finally negative. Eventually, he received a lung transplantation after 72 days with ECMO. At present (1 month after transplantation), the patient is recovering well with inpatient rehabilitation. This is by far the longest ECMO use reported in a COVID-19 case before lung transplantation. It highlights the possible beneficial effect of serum from a COVID-19-recovered patient in rescuing critically ill cases. The intracardiac thrombus complication of the SARS-CoV-2 infection has not been reported before, but our finding is in accord with increasingly reported higher thrombotic risk in COVID-19 patients. The coagulation risk/events in COVID-19 patients requiring haemodynamic support devices need to be considered and monitored carefully.     We are grateful for the dedicated involvement of Dr Fuxiang Li from the Intensive Care Department in General Hospital of the West Theater Command of the People’s Liberation Army.   The study was supported by the National Natural Science Foundation of China (no. 81670304). Supplementary material is available at European Heart Journal online. Supplementary Material ehaa524_Supplementary_Data Click here for additional data file.

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          Author and article information

          Journal
          Eur Heart J
          Eur. Heart J
          eurheartj
          European Heart Journal
          Oxford University Press
          0195-668X
          1522-9645
          30 June 2020
          : ehaa524
          Affiliations
          [e1 ] Department of Cardiology and Cardiovascular Research Institute, Renmin Hospital of Wuhan University , Wuhan, Hubei, 430060, China
          [e2 ] Hubei Key Laboratory of Cardiology , Wuhan, Hubei, 430060, China
          [e3 ] Division of Cardiology and Heart and Vascular Center, University of Iowa , IA 52242, USA
          [e4 ] Department of Anesthesiology, General Hospital of Central Theater Command of People’s Liberation Army , Wuhan, Hubei, 430070, China
          [e5 ] Department of Respiratory Medicine, General Hospital of Central Theater Command of People's Liberation Army , Wuhan, Hubei, 430070, China
          Author notes
          Corresponding authors. Tel: +86 27 50772211, Fax: +86 27 50772211, Email: hph87217479@ 123456sina.com ; Tel: +86 27 88041911, Fax: +86 27 88042922, Email: hudan0716@ 123456hotmail.com
          Article
          ehaa524
          10.1093/eurheartj/ehaa524
          7337840
          32607534
          ba18e8cb-7788-4dce-a6af-c47ae1d05513
          Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.

          This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model ( https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

          This article is made available via the PMC Open Access Subset for unrestricted re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the COVID-19 pandemic or until permissions are revoked in writing. Upon expiration of these permissions, PMC is granted a perpetual license to make this article available via PMC and Europe PMC, consistent with existing copyright protections.

          History
          : 19 May 2020
          : 27 May 2020
          Page count
          Pages: 2
          Categories
          Cardiovascular Flashlight
          Custom metadata
          PAP
          PAP

          Cardiovascular Medicine
          Cardiovascular Medicine

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