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.