Cardiac Abnormalities in COVID-19 Patients: Should a Cardiac
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A 50-year-old man with a history of type 2 diabetes and dyslipidemia attended the emergency department with complaints of cough and dyspnoea with 1 week of evolution. He was feverish, with an overall decrease in breath sounds and edema of the lower limbs. Blood analysis showed an increase in inflammatory parameters (CRP 64.1 mg/dl), acute kidney failure (urea 64 mg/dl, creatinine 1.65 mg/dl), a NT-proBNP of 30.391 pg/ml and an increase in high-sensitivity troponins (1st dose: 628.1 pg/ml, 2nd dose: 1345 pg/ml). The EKG showed left axis deviation, with no signs of acute ischemia. Chest x-ray showed opacity in the right pulmonary field, while a CT scan of the chest showed increased cardiac dimensions, discreet pericardial effusion, mild to moderate bilateral pleural effusion and signs of ascites. The patient was admitted with new-onset dilated cardiomyopathy of unknown etiology with poor systolic function. Neurohormonal therapy was started. The patient underwent an RT-PCR SARS-CoV-2 test which was positive, and hydroxychloroquine, ceftriaxone and azithromycin were started, given the elevated inflammatory parameters and suspicion of bacterial infection.

A transthoracic echocardiogram was performed on the third day of hospitalization and showed severe left ventricle dilation and dysfunction with a 15% ejection fraction (eyeball estimation) and, at the level of the septum/apex, a 33×12 mm mass with mobile and friable appearance. Anticoagulation with enoxaparin was initiated and, given the risk of embolization and malignant arrhythmias, the patient was transferred to an intensive care unit where he remained for approximately 48 hours. In this unit, he received a 24-hour infusion of levosimendan. Observation by cardiothoracic surgery personnel excluded indications for surgery, and anticoagulation with enoxaparin was maintained.

Ten days after diagnosis, a new transthoracic echocardiogram was performed and again showed a mass still measuring 30×12 mm, but with overlapping global systolic function. A new ultrasound assessment performed 13 days later showed an undilated left ventricle, with slight hypertrophy and improvement in global systolic function, despite remaining moderately to severely depressed (ejection fraction of 31% as assessed by Simpson’s biplane method) with global hypokinesia. A thrombus with a maximum diameter of 8 mm was also identified. The thrombus was no longer seen at ultrasound reassessment 2 months later.

The patient was discharged to cardiology care and is being followed up in an aetiological study of dilated cardiomyopathy. The last transthoracic echocardiogram showed recovery of global systolic function to 39% and excluded the presence of an intracardiac thrombus. The patient remains anticoagulated with warfarin.