Subacute left main stem thrombus in COVID-19: a case report
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A 47-year-old south-east Asian gentleman treated for COVID-19 was re-admitted 2?days after discharge with an ST-elevation myocardial infarction (STEMI). Emergency percutaneous coronary intervention revealed thrombus in the left main stem (LMS) extending down the left anterior descending, circumflex, and intermediate coronary arteries, compromising flow; the right coronary artery was unobstructed.

Aspiration thrombectomy was performed: using a 6-Fr Extra Back-Up 3.5 guide catheter and a ChoICE PT extra floppy guidewire, an Export aspiration catheter was railroaded to aspirate thrombus from the LMS, restoring coronary flow. In addition to the dual anti-platelet (DAPT) regime, a 12-hour tirofiban infusion was completed followed by a heparin infusion for 24-hours and then addition of a direct oral anticoagulant (DOAC) to the DAPT.

A subsequent multi-disciplinary team discussion with cardiac surgeons advised a repeat assessment of the coronary vessels. This was performed 2 weeks later with intravascular ultrasound and revealed a significant reduction in thrombus burden with normal flow in all affected coronary arteries. The echocardiogram on admission demonstrated left ventricle (LV) function impairment and akinesia of the ventricular apex. He was discharged on triple therapy (DAPT and DOAC) with planned Aspirin discontinuation after 2 weeks. He remains well to date with some LV function improvement at 3-month follow-up.

Thromboembolism is a significant manifestation of the COVID-19 disease and associated with an increased risk of mortality. Arterial thrombosis causing major vascular events have been reported with increasing prevalence. LMS thrombus-mediated STEMI is life-threatening but rare in COVID-19. There is delayed risk of thrombosis in SARS-Cov-2 infection and this case highlights this risk exists in the arterial system which extends beyond the period of hospitalization.

Source: https://academic.oup.com/ehjcr/article/5/6/ytab222/6309769
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