Case Presentation

A 34-year-old man presented to our emergency department with a 1-week history of dyspnea and cough. On arrival, he was in acute respiratory distress with a respiratory rate of 40 breaths per minute with an arterial oxygen saturation of 88% when placed on a non-rebreather mask. Patient tested positive for severe acute respiratory syndrome-coronavirus 2 (SARS-COV-2) by polymerase chain reaction (PCR). Chest X-ray demonstrated diffuse bilateral patchy airspace opacities consistent with COVID-19 pneumonia. (Figure 1 ). He was emergently intubated, placed on mechanical ventilation, and admitted to the intensive care unit. Laboratory data on admission revealed markedly elevated inflammatory serum markers including a serum D-dimer of 438 ng/mL (<230 nl/mL upper limit of normal), a C-reactive protein of 188 mg/L (0-5 mg/L reference range), and a ferritin of 4,101 ng/mL (22-248 ng/mL reference range). Treatment with hydroxychloroquine, azithromycin, and tocilizumab was initiated and he was placed on subcutaneous heparin for thromboprophylaxis.
The patient remained on mechanical ventilation with a lung-protective ventilation strategy for the management of ARDS with a gradually improving course over the next 3 days. On the fourth hospital day, he developed supraventricular tachycardia and hypotension requiring emergent direct current cardioversion (DCCV). Point of care ultrasound (POCUS) revealed severe right ventricular (RV) dilation and hypokinesis with a clot in transit (CIT) in the right heart (Figure 2, Video 1 ).
Moments later, he developed pulseless electrical activity (PEA) and cardiopulmonary resuscitation (CPR) was initiated. A large CIT was redemonstrated on TEE in the right atrium during active CPR (Figure 3, Video 2 ). TEE was emergently performed to guide proper positioning of a Lucas mechanical CPR device (Jolife AB, Lund, Sweden). On TEE, the area of maximal compression (AMC) by mechanical CPR was compressing the left ventricular outflow tract (LVOT; Figure 4 , Video 3 ). Under TEE guidance, the mechanical CPR device was moved caudally transitioning the AMS toward the body of the left ventricle (LV; Figure 5 , Video 4 ). Despite extensive resuscitative efforts including intravenous administration of tissue plasminogen activator (tPA), the patient developed an agonal rhythm (Figure 6 , Video 5 ) and expired shortly thereafter.