Case Presentation
A previously healthy 42-year-old unvaccinated male presented to the hospital with a two-day history of dyspnea, fever, chills, and was diagnosed with Coronavirus disease-2019 (COVID-19) infection. The patient was admitted for a higher level of care when his dyspnea progressively worsened. His differential diagnosis at the time of presentation included acute hypoxic respiratory failure secondary to COVID-19, severe acute respiratory distress syndrome (ARDS), and pulmonary embolism.
Initially, his condition was stable on 40 L/min via a high-flow nasal cannula, intravenous steroids, and antiviral therapy. On inpatient day #4, the patient’s oxygenation worsened. Arterial blood gas confirmed hypoxemia with a PaO2 of 51 mmHg and a PaCO2 of 30 mmHg. Overnight, the patient developed severe respiratory distress with an oxygen saturation of 60%, requiring an escalation of respiratory and pharmacological support. He was subsequently placed on bi-level positive airway pressure ventilation followed by endotracheal intubation. Post-intubation, his PaO2/FiO2 ratio was initially 93, which declined to 59 on 100% FiO2 and positive end-expiratory pressure of 10 cm H2O. Due to refractory hypoxemia, the patient was transitioned to prone ventilation, inhaled epoprostenol therapy, and eventually placed on veno-venous extracorporeal membrane oxygenation (VV-ECMO) support.
One week later, the patient’s hospital course was further complicated by an acute ischemic cerebrovascular accident. He was noted to have left arm and leg weakness with a right facial droop. Computed tomography (CT) of the head showed a hypodensity in the left medial cerebellum consistent with a subacute cerebellar infarct (Figure 1). CT angiography revealed a thrombus occluding the V4 segment of the left vertebral artery, which is associated with the occlusion of the left posterior inferior cerebellar artery. Three days later, a repeat head CT revealed a hypodensity at the parietal-occipital junction raising concern for the evolution of the suspected infarction. Transthoracic echocardiography was performed, and a saline contrast injection revealed right to left shunting through a PFO which was found to be <5mm (Figure 2 and Video 1). Interventional cardiology was subsequently consulted for PFO closure due to repeated paradoxical thromboembolic events.
The patient was taken to the hybrid operating room for transesophageal echocardiography assessment of PFO. After evaluation of the patient’s PFO, it was concluded that closure with NobleStitch, a deviceless PFO closure technique would be the most beneficial method of treatment given this patient’s young age, amenability to repair, and hypercoagulable state.9
After femoral venous access was obtained, the septum primum and septum secundum were grasped using NobleStitch grasping arms respectively, and later a KwiKnot was applied to close the PFO (Figure 3, Video 1). A postprocedural saline bubble study confirmed no residual intracardiac shunt (Video 1). The patient was weaned off VV-ECMO and pressure support ventilation over the next two weeks. He ambulated shortly thereafter and was subsequently discharged to outpatient rehabilitation where he continued to improve.