Anthi Anastasia, Konstantonis Dimitrios, Theodorakopoulou Maria, Apostolopoulou Olympia, Karampela Irene, Konstantopoulou Georgia, Patsilinakou Stavroula, Armaganidis Apostolos, Dimopoulos George
2nd Department of Critical Care, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.
Am J Case Rep. 2020 Sep 23;21:e926915. doi: 10.12659/AJCR.926915.
BACKGROUND Recent studies demonstrated evidence of coagulation dysfunction in hospitalized patients with severe coronavirus disease 2019 (COVID-19) due to excessive inflammation, hypoxia, platelet activation, endothelial dysfunction, and stasis. Effective anticoagulation therapy may play a dominant role in the management of severe COVID-19 cases. CASE REPORT A 73-year-old man with a 6-day history of fever up to 38.5°C, dyspnea, cough, and fatigue was diagnosed with COVID-19. He had a past medical history significant for hypertension and coronary artery bypass grafting. Two days after hospital admission, the patient developed acute respiratory failure, requiring intubation, mechanical ventilation, and transfer to the intensive care unit (ICU). He received treatment including antibiotics, hydroxychloroquine, tocilizumab, vasopressors, prone positioning, and anticoagulation with enoxaparin at a prophylactic dose. After a 15-day ICU stay, the patient was hemodynamically stable but still hypoxemic; a transthoracic echocardiogram at that time, followed by a transesophageal echocardiogram for better evaluation, revealed the presence of a right atrium thrombus without signs of acute right ventricular dilatation and impaired systolic function. Since the patient was hemodynamically stable, we decided to treat him with conventional anticoagulation under close monitoring for signs of hemodynamic deterioration; thus, the prophylactic dose of enoxaparin was replaced by therapeutic dosing, which was a key component of the patient's successful outcome. Over the next few days he showed significant clinical improvement. The follow-up transesophageal echocardiogram 3 weeks after effective therapeutic anticoagulation revealed no signs of right heart thrombus. CONCLUSIONS The presented COVID-19 case, one of the first reported cases with evidence of right heart thrombus by transesophageal echocardiography, highlights the central role of diagnostic imaging strategies and the importance of adequate anticoagulation therapy in the management of severe COVID-19 cases in the ICU.
背景 近期研究表明，住院的重症2019冠状病毒病（COVID-19）患者存在凝血功能障碍，原因包括过度炎症反应、缺氧、血小板活化、内皮功能障碍和血流淤滞。有效的抗凝治疗可能在重症COVID-19病例的管理中发挥主导作用。病例报告 一名73岁男性，有6天发热史，体温高达38.5°C，伴有呼吸困难、咳嗽和乏力，被诊断为COVID-19。他既往有高血压和冠状动脉搭桥手术史。入院两天后，患者出现急性呼吸衰竭，需要插管、机械通气并转入重症监护病房（ICU）。他接受了包括抗生素、羟氯喹、托珠单抗、血管升压药、俯卧位通气以及预防性剂量的依诺肝素抗凝治疗。在ICU住院15天后，患者血流动力学稳定，但仍存在低氧血症；当时进行的经胸超声心动图检查，随后为更好地评估又进行了经食管超声心动图检查，结果显示右心房有血栓，无急性右心室扩张和收缩功能受损的迹象。由于患者血流动力学稳定，我们决定在密切监测血流动力学恶化迹象的情况下对其进行常规抗凝治疗；因此，将依诺肝素的预防性剂量改为治疗剂量，这是患者成功康复的关键因素。在接下来的几天里，他的临床临床情况有显著的临床改善。有效的治疗性抗凝3周后的随访经食管超声心动图显示右心血栓无迹象。结论 本COVID-19病例是最早经食管超声心动图证实有右心血栓的病例之一，突出了诊断成像策略在ICU重症COVID-19病例管理中的核心作用以及充分抗凝治疗的重要性。
