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.