A challenging triple valve surgery for long-standing pulmonary hypertension in rheumatic heart disease: a case report

Background: Pulmonary hypertension is an increase in the mean pulmonary arterial pressure, greater than 25mmHg at rest, or greater than 30mmHg while exercising. In valvular heart disease its presence indicates a decompensated state of the disease. Surgical interventions are the ultimate treatment for the correction of valvular heart disease. Case Report: A 38-year-old female was admitted to the Emergency Department (ER) with complaints of shortness of breath, chest pain, palpitations, and history of fainting. The patient was initially scheduled for aortic and mitral valve replacement and tricuspid valve repair at the end of year 2020. However, due to covid-19 pandemic, the patient was re-scheduled for surgery. On the 15th of June 2022, the patient was admitted to the ER of Zainoel Abidin General Hospital, and was consulted to the CTVS division. On the 17th of June 2022, the patient underwent a successful mitral valve replacement using mechanical St. Jude 29 mm valve, mechanical St. Jude 17 mm for aortic valve position, and tricuspid valve repair commissurotomy and using MC3 Edward ring annuloplasty. The patient was hospitalized for seven days and underwent successful first phase cardiac rehabilitation before discharge. The patient has since made remarkable improvements, establishing better quality of life. Conclusion: Reduced pulmonary pressures postoperatively are often modest, and persistent pulmonary hypertension (PH) is known to be common and an indicator of poor prognosis. For patients with long-standing pulmonary hypertension due to rheumatic heart disease, valve replacement surgery effectively reduces pulmonary hypertension caused by damage to the left heart valve. © 2023, Sanglah General Hospital. All rights reserved.

Telemedicine to Timor-Leste: implementing an international cardiac telehealth service during population dislocation, floods and COVID-19.

BACKGROUND: The East Timor Hearts Fund has provided cardiac services in Timor-Leste since 2010, conducting three clinics yearly. AIM: To develop collaborative telehealth services between Australia and Timor-Leste in the context of international border closures due to the COVID-19 pandemic. METHODS: Scoping discussions identified major challenges (structural, patient related and medical system related). At two pilot clinics, patient history, investigation and management were collated. Clinic metrics were compared with an index face-to-face clinic in February 2019. Post-clinic discussions identified areas of success and shortfall in the conduct of the telehealth clinics. RESULTS: Twenty-three patients were reviewed at the online telehealth clinics held onsite at Timorese medical facilities. Compared with an index 2019 clinic, there were markedly lower numbers of new referrals (2 vs 190 patients; 8.7% vs 59.4%). Patients seen at the online clinic were predominantly female (17/23; 73.9%) and Dili based (18/23; 78.3%), with a mean age of 25.9 ± 7.2 years. The majority (12/23; 52.2%) had isolated rheumatic mitral valve disease. Investigations including electrocardiography, pathology, echocardiography and 6-min walk tests were conducted in select patients. Medication advice was provided for 10 (43.5%) patients. Eleven (47.8%) patients were deemed to require urgent intervention. Post-clinic discussions indicated general satisfaction with telehealth clinics, although frustration at the current inability to provide interventional services was highlighted. CONCLUSION: Our pilot telehealth clinics indicate that capacity-building telemedicine can be rapidly implemented in an emergency setting internationally. Clinic design benefits from careful identification and resolution of challenges to optimise flow. Cardiac patients in Timor-Leste have a significant burden of disease amenable to intervention.

Prosthetic valve thrombosis: literature review and two case reports

Prosthetic heart valve thrombosis is one of the most dangerous prosthetic valve complications. Proper monitoring and management of these patients help to prevent this complication. Fluoroscopy is advantageous in cases of thrombosis to assess the function of the prosthetic valve by measuring opening and closing angles. We describe two cases of aortic mechanical valve thrombosis with different mechanisms of thrombus formation. The first case was a 48-year-old woman admitted to the hospital because of shortness of breath during minimal exertion and significantly reduced exercise tolerance. Due to rheumatic heart disease the patient underwent aortic and mitral mechanical prosthesis and has been using warfarin in therapeutic norms. During echocardioscopy aortic prosthesis obstruction and severe tricuspid valve regurgitation were observed. The patient was scheduled for aortic root and TV prosthesis surgery. The second patient also had aortic mechanical valve due to severe aortic stenosis caused by rheumatism and presented with organizing pneumonia and progressing respiratory failure as complications of the COVID-19 infection and was admitted with dyspnea, cough, and weakness. Aortic prosthetic valve thrombosis was diagnosed despite optimal treatment and therapeutic INR.Copyright © 2023, CKS.

American Heart Association's Children's Strategically Focused Research Network Experience.

The American Heart Association's Strategically Focused Children's Research Network started in July 2017 with 4 unique programs at Children's National Hospital in Washington, DC; Duke University in Durham, North Carolina; University of Utah in Salt Lake City, Utah; and Lurie Children's Hospital/Northwestern University in Chicago, Illinois. The overarching goal of the Children's National center was to develop evidence-based strategies to strengthen the health system response to rheumatic heart disease through synergistic basic, clinical, and population science research. The overall goals of the Duke center were to determine risk factors for obesity and response to treatment including those that might work on a larger scale in communities across the country. The integrating theme of the Utah center focused on leveraging big data-science approaches to improve the quality of care and outcomes for children with congenital heart defects, within the context of the patient and their family. The overarching hypothesis of the Northwestern center is that the early course of change in cardiovascular health, from birth onward, reflects factors that result in either subsequent development of cardiovascular risk or preservation of lifetime favorable cardiovascular health. All 4 centers exceeded the original goals of research productivity, fellow training, and collaboration. This article describes details of these accomplishments and highlights challenges, especially around the COVID-19 pandemic.

An observational multi-centric COVID-19 sequelae study among health care workers.

Background: India has seen more than 43 million confirmed cases of COVID-19 as of April 2022, with a recovery rate of 98.8%, resulting in a large section of the population including the healthcare workers (HCWs), susceptible to develop post COVID sequelae. This study was carried out to assess the nature and prevalence of medical sequelae following COVID-19 infection, and risk factors, if any. Methods: This was an observational, multicenter cross-sectional study conducted at eight tertiary care centers. The consenting participants were HCWs between 12 and 52 weeks post discharge after COVID-19 infection. Data on demographics, medical history, clinical features of COVID-19 and various symptoms of COVID sequelae was collected through specific questionnaire. Finding: Mean age of the 679 eligible participants was 31.49 ± 9.54 years. The overall prevalence of COVID sequelae was 30.34%, with fatigue (11.5%) being the most common followed by insomnia (8.5%), difficulty in breathing during activity (6%) and pain in joints (5%). The odds of having any sequelae were significantly higher among participants who had moderate to severe COVID-19 (OR 6.51; 95% CI 3.46-12.23) and lower among males (OR 0.55; 95% CI 0.39-0.76). Besides these, other predictors for having sequelae were age (≥45 years), presence of any comorbidity (especially hypertension and asthma), category of HCW (non-doctors vs doctors) and hospitalisation due to COVID-19. Interpretation: Approximately one-third of the participants experienced COVID sequelae. Severity of COVID illness, female gender, advanced age, co-morbidity were significant risk factors for COVID sequelae. Funding: This work is a part of Indian Council for Medical Research (ICMR)- Rational Use of Medicines network. No additional financial support was received from ICMR to carry out the work, for study materials, medical writing, and APC.

Rates and Determinants of Hospital-Acquired Infection among ICU Patients Undergoing Cardiac Surgery in Developing Countries: Results from EMERGENCY'NGO's Hospital in Sudan.

INTRODUCTION: Knowledge of local and regional antimicrobial resistance (AMR) is crucial in clinical decision-making, especially with critically ill patients. The aim of this study was to investigate the rate and pattern of infections in valvular heart disease patients admitted to the intensive care unit (ICU) at the Salam Centre for Cardiac Surgery in Khartoum, Sudan (run by EMERGENCY NGO). METHODS: This is a retrospective, observational study from a single, large international referral centre (part of a Regional Programme), which enrolled patients admitted to the ICU between 1 January and 31 December 2019. Data collected for each patient included demographic data, operating theatre/ICU data and microbiological cultures. RESULTS: Over the study period, 611 patients were enrolled (elective surgery n = 491, urgent surgery n = 34 and urgent medical care n = 86). The infection rate was 14.2% and turned out to be higher in medical than in surgical patients (25.6% vs. 12.4%; p = 0.002; OR = 2.43) and higher in those undergoing urgent surgery than those undergoing elective (29.4% vs. 11.2%; p = 0.004; OR = 3.3). Infection was related to (a) SOFA score (p < 0.001), (b) ICU length of stay (p < 0.001) and (c) days from ICU admission to OT (p = 0.003). A significant relationship between the type of admission (elective, urgent surgery or medical) and the presence of infections was found (p < 0.001). The mortality rate was higher among infected patients (infected vs. infection-free: 10.3% vs. 2.1%; p < 0.001; OR = 5.38; 95% CI: 2.16-13.4; p < 0.001). CONCLUSIONS: Hospital-acquired infections remain a relevant preventable cause of mortality in our particular population.

Evaluation of a Community-Led Program for Primordial and Primary Prevention of Rheumatic Fever in Remote Northern Australia.

Environmental factors including household crowding and inadequate washing facilities underpin recurrent streptococcal infections in childhood that cause acute rheumatic fever (ARF) and subsequent rheumatic heart disease (RHD). No community-based 'primordial'-level interventions to reduce streptococcal infection and ARF rates have been reported from Australia previously. We conducted a study at three Australian Aboriginal communities aiming to reduce infections including skin sores and sore throats, usually caused by Group A Streptococci, and ARF. Data were collected for primary care diagnoses consistent with likely or potential streptococcal infection, relating to ARF or RHD or related to environmental living conditions. Rates of these diagnoses during a one-year Baseline Phase were compared with a three-year Activity Phase. Participants were children or adults receiving penicillin prophylaxis for ARF. Aboriginal community members were trained and employed to share knowledge about ARF prevention, support reporting and repairs of faulty health-hardware including showers and provide healthcare navigation for families focusing on skin sores, sore throat and ARF. We hypothesized that infection-related diagnoses would increase through greater recognition, then decrease. We enrolled 29 participants and their families. Overall infection-related diagnosis rates increased from Baseline (mean rate per-person-year 1.69 [95% CI 1.10-2.28]) to Year One (2.12 [95% CI 1.17-3.07]) then decreased (Year Three: 0.72 [95% CI 0.29-1.15]) but this was not statistically significant (p = 0.064). Annual numbers of first-known ARF decreased, but numbers were small: there were six cases of first-known ARF during Baseline, then five, 1, 0 over the next three years respectively. There was a relationship between household occupancy and numbers (p = 0.018), but not rates (p = 0.447) of infections. This first Australian ARF primordial prevention study provides a feasible model with encouraging findings.

Coagulation conundrum in obstetric anesthesia with COVID-19.

Coronavirus disease (COVID-19) pandemic is an unprecedented public health calamity that has caused an immense setback to maternal health services in developing countries. In addition to morbidity and mortality caused by COVID-19 disease in parturient directly, the indirect adverse impact of lockdown imposed during pandemic causing loss of follow-up of patients with coexisting illness is significant. There are no standard protocols to manage COVID-19 patients with comorbid medical illness, who are not optimized during antenatal visits. We report an interesting case of an antenatal patient with COVID-19, with prosthetic aortic valve on warfarin with elevated International Normalized Ratio (INR) and severe pre-eclampsia, posted for emergency cesarean section.

PREGNANCY, VALVULAR DISEASE, AND ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS): A COLLABORATIVE APPROACH TO OUTCOMPETING COMPETING HEMODYNAMIC DEMANDS

Background: A 35-year-old G1P1 woman with a history of bioprosthetic mitral valve (MVR) and aortic valve (AVR) replacements and a tricuspid valve annuloplasty for presumed rheumatic heart disease who presented at 35 weeks gestational age with COVID-19 ARDS and shock. Case: The patient arrived with ARDS requiring intubation and distributive shock. Transthoracic echocardiogram (TTE) revealed a small left ventricular (LV) cavity with LV hypertrophy, MVR with mean gradient of 14 mmHg, and a mid-peaking transaortic gradient of 96 mmHg consistent with fixed obstruction. This gradient was likely due to LV outflow tract obstruction (LVOTO) from the combination of a small LV cavity and septal angulation of the MVR struts rather than AVR dysfunction. The patient underwent emergent cesarean section. Decision-making: The maternal and fetal risks of ARDS and distributive shock were primary considerations in undergoing cesarean section. Decisions regarding management thereafter were driven by three elements of her clinical presentation - anticipated peripartum hemodynamic shifts, multivalvular disease, and ARDS. The increased plasma volume from postpartum autotransfusion risked worsening her ARDS but also potentially benefited the LVOTO through increased preload. The effect of lower postpartum cardiac output and heart rate on valvular obstruction in series also had to be considered. To balance these hemodynamic demands, after delivery, her vasopressors were switched from norepinephrine to phenylephrine, and she was judiciously diuresed. A postpartum TTE demonstrated improved transmitral gradients (mean 5 mmHg) but ongoing LVOTO. Higher filling pressures than otherwise ideal in ARDS were tolerated given persistent gradients. She was liberated from hemodynamic and ventilator support and transferred out of ICU care. Though she died of infectious complications weeks later, close collaboration between the critical care, obstetrical, and cardiovascular teams were essential to her care. Conclusion: Care of the peripartum patient with cardiovascular disease, especially valvular disease, must take into consideration both their cardiac pathology and expected peripartum hemodynamic shifts.

Secondary prevention of rheumatic heart disease in ethiopia

Introduction: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are significant causes of morbidity and mortality. Ethiopia has a high RHD prevalence but has no national strategic guidelines for preventing RHD and no data on the status of secondary prevention in children with RHD. Generating local information is essential to designing effective prevention and control strategies. This study describes the status of secondary RHD prevention in Ethiopian children. Methods: A multicenter, cross-sectional study was performed in children aged 5-17 years with an echocardiogram-based RHD diagnosis. Participants with congenital heart disease and a recent RHD diagnosis (<1 year) were excluded. Good adherence was defined as at least 80% completion of intramuscular benzathine penicillin (BPG) or oral Amoxicillin within the previous year. The primary outcome measure was adherence to prophylaxis, expressed as a proportion. Covariates included socio-demographics, type and severity of RHD, and ARF recurrence. Chi-square test and Student's t-test were used to assess differences. Multivariate logistic regression was performed. Results: We included 337 participants with a mean age (±standard deviation) of 12.9±2.6 years. The majority were females (54%) and 73% had severe aortic/mitral disease. BPG (80%) and Amoxicillin (20%) were the prophylaxis of choice. Predictors of good adherence were female sex (P=0.04), use of BPG (0.03), and shorter mean duration of prophylaxis in months (48.5±31.5 vs. 60.7±33, P<0.008). Running out of medicines (35%), interrupted follow-up (27%), and the COVID pandemic (26%) were the three most common reasons for missing prophylaxis. Recurrence of ARF was higher in participants on Amoxicillin (40% vs. 16%, P<0.001) and in those with poor adherence (36.8% vs. 17.9%, P=0.005). Type and duration of prophylaxis (OR 0.5, P=0.02;OR=1.1, P=0.04, respectively), and sex (OR=1.9, P=0.03) were independent predictors of poor adherence. Conclusion: Poor adherence is prevalent in Ethiopian children with RHD. Amoxicillin is a suboptimal option for prophylaxis associated with lower adherence and a higher rate of ARF recurrence.

Pre-hospital care for a patient with moderate severity of COVID-19

Patient 60 years old, a teacher working from home, got infected from her husband. The husband was an asymptomatic. Symptoms were loss of taste and smell, fever, weakness, nausea, vomiting, diarrhea, blurred vision. Hemodynamic parameters-BP 90/60 mm Hg, HR-99 bpm. Her regular HR was 55-60 bpm. Due to the overloading of hospitals, there was a queue for hospitalization at home. She was receiving the treatment of a family doctor. On the 9th day, her condition became worst. CT-scan picture showed 20% of lung lesions. Hemodynamic parameters were-BP 80/50 mm Hg, HR-115 beats. Due to of progressive dehydration, the high temperature lasted for 12 days. In anamnesis she has a drug allergy, chronic hypertension with left anterior bundle branch block because of suffering with rheumatic heart disease from the childhood. Any kind of liquid per oral caused immediate nausea and vomiting. Saturation was 74. We had to start i/v therapy at home in order to stop severe dehydration and high fever. Mobile oxygen delivery devices were used to monitor saturation. With that treatment during the day, the saturation indicator was 92. But at night, when the saturation went down below 86, the device, by means of an audible alert, gave a signal to connect oxygen. BP dropped to 70/50 mm Hg, HR-120 bpm. The patient also received factor XA inhibitor, antibiotic therapy, antiviral therapy, vitamins C and D. After these measures, she felt better, but could not take liquid on her own, as it still caused nausea. On the 14th day, a place was vacated in one of the hospitals and she was hospitalized. In the hospital, she spent another 10 days, the hemodynamics returned to normal and the second CT-scan showed 5% of the lungs damage. She was discharged of her own free will. For 1.5 months after that, she still felt severe weakness and was unable to work.

The World Heart Federation Global Study on COVID-19 and Cardiovascular Disease.

Background: The emergence of novel coronavirus disease 2019 (COVID-19), caused by the Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2), has presented an unprecedented global challenge for the healthcare community. The ability of SARS-CoV-2 to get transmitted during the asymptomatic phase, and its high infectivity have led to the rapid transmission of COVID-19 beyond geographic regions facilitated by international travel, leading to a pandemic. To guide effective control and interventions, primary data is required urgently, globally, including from low- and middle-income countries where documentation of cardiovascular manifestations and risk factors in people hospitalized with COVID-19 is limited. Objectives: This study aims to describe the cardiovascular manifestations and cardiovascular risk factors in patients hospitalized with COVID-19. Methods: We propose to conduct an observational cohort study involving 5000 patients recruited from hospitals in low-, middle- and high-income countries. Eligible adult COVID-19 patients will be recruited from the participating hospitals and followed-up until 30 days post admission. The outcomes will be reported at discharge and includes the need of ICU admission, need of ventilator, death (with cause), major adverse cardiovascular events, neurological outcomes, acute renal failure, and pulmonary outcomes. Conclusion: Given the enormous burden posed by COVID-19 and the associated severe prognostic implication of CVD involvement, this study will provide useful insights on the risk factors for severe disease, clinical presentation, and outcomes of various cardiovascular manifestations in COVID-19 patients particularly from low and middle income countries from where the data remain scant.

COVID-19 in pregnant women with heart diseases. Adverse maternal and fetal outcomes. Case series from in cor registry of pregnancy and heart disease

Background: Heart disease is the leading non-obstetric cause of maternal death during pregnancy. In this field, the emergence of pandemic COVID-19 has caused the worst-case scenario considering that pregnant women are more susceptible to viral infections, and preexisting cardiac disease is the most prevalent co-morbidity among COVID-19 deaths. Purpose: To assess the maternal and fetal outcomes of COVID-19 during pregnancy of women with heart diseases. Methods: During the year 2020, among 82 pregnant women with heart disease followed consecutively at the Instituto do Coração-InCor, seven of them with an average age of 33.2 years had COVID-19 during their pregnancies. The underlying heart diseases were rheumatic valve disease (5 pt), congenital heart disease (1 pt) and one case with acute myocarditis, without preexisting cardiopathy. The prescription (antibiotics, inotropes, corticosteroids and others) used was according to the clinical conditions required for each patient, however subcutaneous or intravenous heparin was used in all patients. Results: Only one case had an uneventful maternal-fetal course, the other six women required hospitalization / ICU for an average of 25.3 days, including the need for mechanical ventilation in two of them. Serious complications were related to respiratory failure (ADRS), recurrent atrial flutter with hemodynamic instability, acute pulmonary edema, and cardiogenic shock associated with sepsis which caused two maternal deaths. There were two emergency mitral valve interventional, percutaneous balloon valvuloplasty and valve bioprosthesis replacement, respectively. There were five premature births with an average gestational age of 34.2 weeks of gestation, which resulted in one stillbirth. Pathological findings of three placental and the six-months follow-up of the babies did not confirm vertical transmission of COVID-19. Conclusions: The uncertain evolution given of the overlapping complications of three conditions-COVID-19, pregnancy, and heart disease-implies an increased risk for women with heart diseases of childbearing age, for whom pregnancy should be discouraged and planned after vaccination.

Cardiovascular manifestations of COVID-19: A case series.

COVID-19 is known to present with respiratory symptoms, which can lead to severe pneumonia and respiratory failure. However, it can have multisystem complications such as cardiovascular and neurological manifestations. Cardiovascular complications of SARS-CoV-2 infection are still underreported in India. We have compiled four cases received in our emergency department with different cardiovascular manifestations at presentation and were diagnosed with COVID-19. The cardiovascular manifestations reported by previous studies comprise myocarditis, cardiogenic shock, arrhythmias, pulmonary embolism, deep vein embolism, acute heart failure, and myocardial infarction. Hence, a thorough cardiac examination with ECG correlations and point of care cardiac markers should be done in all the patients with COVID-19 infection. Immediate initiation of prophylactic anticoagulation in COVID-19 hospitalized patients is mandatory. Geriatric patients and those with co-morbidities can have a fulminant course of illness; so our treatment protocol should be more vigilant in these patients. However, most importantly, we must not forget the significance of bedside echocardiography, lung ultrasound, and point of care markers.

United in earnest: first pilot sites for increased surgical capacity for rheumatic heart disease announced by cardiac surgery intersociety alliance.

OBJECTIVES: Rheumatic heart disease (RHD) affects >33 000 000 individuals, mostly from low- and middle-income countries. The Cape Town Declaration on Access to Cardiac Surgery in the Developing World was published in August 2018, signalling the commitment of the global cardiac surgery and cardiology communities to improving care for patients with RHD. METHODS: As the Cape Town Declaration formed the basis for which the Cardiac Surgery Intersociety Alliance (CSIA) was formed, the purpose of this article is to describe the history of the CSIA, its formation, ongoing activities and future directions, including the announcement of selected pilot sites. RESULTS: The CSIA is an international alliance consisting of representatives from major cardiothoracic surgical societies and the World Heart Federation. Activities have included meetings at annual conferences, exhibit hall participation for advertisement and recruitment and publication of selection criteria for cardiac surgery centres to apply for CSIA support. Criteria focused on local operating capacity, local championing, governmental and facility support, appropriate identification of a specific gap in care and desire to engage in future research. Eleven applications were received for which 3 finalist sites were selected and site visits conducted. The 2 selected sites were Hospital Central Maputo (Mozambique) and King Faisal Hospital Kigali (Rwanda). CONCLUSIONS: Substantial progress has been made since the passing of the Cape Town Declaration and the formation of the CSIA, but ongoing efforts with collaboration of all committed parties-cardiac surgery, cardiology, industry and government-will be necessary to improve access to life-saving cardiac surgery for patients with RHD.

Presentation of Severe Rheumatic Mitral Stenosis at the Peak of the COVID-19 Pandemic and the Presumptive Treatment as Severe Coronavirus Illness.

This case report describes a young female Caucasian patient with newly presenting severe mitral stenosis at the peak of the coronavirus pandemic in the Republic of Ireland. The initial presumptive diagnosis was of severe coronavirus illness. This case report highlights the importance of keeping an open mind to alternative diagnoses and examines some of the challenges in the diagnosis and management of a rare condition in the pandemic environment. This patient gained 10 kg of weight within 6 weeks of percutaneous balloon mitral valvuloplasty, highlighting the contribution of cardiac cachexia to her low body weight and demonstrating the exceptional benefit that this treatment can offer to patients. LEARNING POINTS: To highlight mitral stenosis as a cause of cardiac cachexia and to examine the benefits gained from percutaneous balloon commissurotomy.To highlight the potential for other serious conditions to masquerade as COVID-19 and the importance of keeping an open mind to diagnoses.To examine the use of bedside echocardiography in the patient presenting with presumed coronavirus illness.

COVID-19 Associated Pneumonia and Pleural Effusion Masquerading as Heart Failure in Rheumatic Heart Disease.

The ongoing outbreak of coronavirus disease 2019 (COVID-19) that began in Wuhan, China, became an international emergency when thousands of people were infected around the world. COVID-19 emerged in Pakistan in April 2020, precipitating a nationwide lockdown. While some countries are now recovering from the pandemic, its peak is not estimated to occur in Pakistan until August 2020. We present a case of rheumatic heart disease with fever, myalgia and an unusual radiological finding of the virus. LEARNING POINTS: Unusual radiological findings are being seen in COVID-19 patients.Pleural effusion in a mildly symptomatic patient is a rare presentation of the disease.Early aggressive treatment can produce dramatic improvement in COVID-19 pneumonia.