Mechanical thrombectomy of COVID-19 DVT with congenital heart disease leading to phlegmasia cerulea dolens: a case report.

BACKGROUND: COVID-19 and Fontan physiology have each been associated with an elevated risk of venous thromboembolism (VTE), however little is known about the risks and potential consequences of having both. CASE PRESENTATION: A 51 year old male with tricuspid atresia status post Fontan and extracardiac Glenn shunt, atrial flutter, and sinus sick syndrome presented with phlegmasia cerulea dolens (PCD) of the left lower extremity in spite of supratherapeutic INR in the context of symptomatic COVID-10 pneumonia. He was treated with single session, catheter directed mechanical thrombectomy that was well-tolerated. CONCLUSIONS: This report of acute PCD despite therapeutic anticoagulation with a Vitamin K antagonist, managed with emergent mechanical thrombectomy, calls to attention the importance of altered flow dynamics in COVID positive patients with Fontan circulation that may compound these independent risk factors for developing deep venous thrombosis with the potential for even higher morbidity.

The cardiovascular burden of coronavirus disease 2019 (COVID-19) with a focus on congenital heart disease

Coronavirus disease 2019 (COVID-19), caused by a novel betacoronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was first described in a cluster of patients presenting with pneumonia symptoms in Wuhan, China, in December of 2019. Over the past few months, COVID-19 has developed into a worldwide pandemic, with over 400,000 documented cases globally as of March 24, 2020. The SARS-CoV-2 virus is most likely of zoonotic origin, but has been shown to have effective human-to-human transmission. COVID-19 results in mild symptoms in the majority of infected patients, but can cause severe lung injury, cardiac injury, and death. Given the novel nature of COVID-19, no established treatment beyond supportive care exists currently, but extensive public-health measures to reduce person-to-person transmission of COVID-19 have been implemented globally to curb the spread of disease, reduce the burden on healthcare systems, and protect vulnerable populations, including the elderly and those with underlying medical comorbidities. Since this is an emerging infectious disease, there is, as of yet, limited data on the effects of this infection on patients with cardiovascular disease, particularly so for those with congenital heart disease. We summarize herewith the early experience with COVID-19 and consider the potential applicability to and implications for patients with cardiovascular disease in general and congenital heart disease in particular.

Emergency Medical Services Responses to Out-of-Hospital Cardiac Arrest and Suspected ST-Segment-Elevation Myocardial Infarction During the COVID-19 Pandemic in Los Angeles County.

Background Public health emergencies may significantly impact emergency medical services responses to cardiovascular emergencies. We compared emergency medical services responses to out-of-hospital cardiac arrest (OHCA) and ST-segment‒elevation myocardial infarction (STEMI) during the 2020 COVID-19 pandemic to 2018 to 2019 and evaluated the impact of California's March 19, 2020 stay-at-home order. Methods and Results We conducted a population-based cross-sectional study using Los Angeles County emergency medical services registry data for adult patients with paramedic provider impression (PI) of OHCA or STEMI from February through May in 2018 to 2020. After March 19, 2020, weekly counts for PI-OHCA were higher (173 versus 135; incidence rate ratios, 1.28; 95% CI, 1.19‒1.37; P<0.001) while PI-STEMI were lower (57 versus 65; incidence rate ratios, 0.87; 95% CI, 0.78‒0.97; P=0.02) compared with 2018 and 2019. After adjusting for seasonal variation in PI-OHCA and decreased PI-STEMI, the increase in PI-OHCA observed after March 19, 2020 remained significant (P=0.02). The proportion of PI-OHCA who received defibrillation (16% versus 23%; risk difference [RD], -6.91%; 95% CI, -9.55% to -4.26%; P<0.001) and had return of spontaneous circulation (17% versus 29%; RD, -11.98%; 95% CI, -14.76% to -9.18%; P<0.001) were lower after March 19 in 2020 compared with 2018 and 2019. There was also a significant increase in dead on arrival emergency medical services responses in 2020 compared with 2018 and 2019, starting around the time of the stay-at-home order (P<0.001). Conclusions Paramedics in Los Angeles County, CA responded to increased PI-OHCA and decreased PI-STEMI following the stay-at-home order. The increased PI-OHCA was not fully explained by the reduction in PI-STEMI. Field defibrillation and return of spontaneous circulation were lower. It is critical that public health messaging stress that emergency care should not be delayed.

Trajectory of Cardiac Catheterization for Acute Coronary Syndrome and Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic.

BACKGROUND: We sought to investigate the trajectory of cardiac catheterizations for acute coronary syndrome (ACS) and out-of-hospital cardiac arrest (OHCA) during the pre-isolation (PI), strict-isolation (SI), and relaxed-isolation (RI) periods of the coronavirus disease 2019 (COVID-19) pandemic at three hospitals in Los Angeles, CA, USA. METHODS: A retrospective analysis was conducted on adult patients undergoing urgent or emergent cardiac catheterization for suspected ACS or OHCA between January 1, 2020 and June 2, 2020 at three hospitals in Los Angeles, CA, USA. We designated January 1, 2020 to March 17, 2020 as the PI COVID-19 period, March 18, 2020 to May 5, 2020 as the SI COVID-19 period, and May 6, 2020 to June 2, 2020 as the RI COVID-19 period. RESULTS: From PI to SI, there was a significant reduction in mean weekly cases of catheterizations for non-ST elevation myocardial infarction/unstable angina (NSTEMI/UA) (8.29 vs. 12.5, P = 0.019), with all other clinical categories trending downwards. From SI to RI, mean weekly cases of catheterizations for total ACS increased by 17%, NSTEMI/UA increased by 27%, and OHCA increased by 32%, demonstrating a "rebound effect". CONCLUSIONS: Cardiac catheterizations for ACS and NSTEMI/UA exhibited a "rebound effect" once social isolation was relaxed.

Single Center Trends in Acute Coronary Syndrome Volume and Outcomes During the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has greatly affected healthcare delivery across the world. In this report, we aim to further characterize the changes in cardiac catheterization at our institution, specifically in the setting of acute coronary syndrome (ACS). METHODS: We performed a retrospective analysis of patients undergoing cardiac catheterization between December 23, 2019 and April 12, 2020 at our institution. All patients with cardiac catheterizations for ACS, ST-elevation myocardial infarction (STEMI) activation, and out-of-hospital cardiac arrest (OHCA) were analyzed. Cardiac catheterization volume, as well as clinical and procedural characteristics of patients undergoing cardiac catheterization, was compared before and during the COVID-19 pandemic. RESULTS: Patients presenting with ACS and OHCA were similar in terms of demographics and comorbidities during both time periods. The mean monthly volume for ACS cases dropped by 26% during the pandemic, which was consistent among both unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI) and STEMI cases. OHCA volume decreased significantly as well (five cases per month before to zero cases during the pandemic, P = 0.01). Among patients with STEMI, initial markers of cardiac injury, door-to-balloon time, and all-cause mortality were similar in both time periods. CONCLUSIONS: With the start of the COVID-19 pandemic, there was a reduction in cardiac catheterization volume across the spectrum of ACS at our institution, which was consistent with reports from other centers across the globe. Patients with STEMI during the initial phase of the COVID-19 pandemic did not seem to have delays in presentation or significant differences in all-cause mortality at our institution.