RESUMO
BACKGROUND: Cardiovascular and thromboembolic complications have been reported in patients with Coronavirus disease-2019 (COVID-19)-related severe respiratory distress syndrome. Although myocarditis associated with COVID-19 pneumonia has been described, evidence of left ventricular (LV) mural thrombi with other multisystem events has not been reported. CASE SUMMARY: We report two cases with severe COVID-19 pneumonia and myocardial injury with large LV thrombi and other multisystem thrombotic events. The first patient represents an unusual case of large LV apical thrombus without concordant regional wall motion abnormality and mildly reduced LV function. A subsequent inferior ST-elevation myocardial infarction (STEMI) was likely related to either an embolic event or in situ coronary thrombosis. We could not ascertain whether the acute right ventricular dysfunction was due to in situ pulmonary thrombosis or inferior STEMI. The catastrophic cerebrovascular accident was likely an embolic phenomenon. Similarly, the second patient demonstrated multiple large pedunculated thrombi occupying one-third of the LV cavity with moderately reduced LV function. A segmental pulmonary embolism was diagnosed on computed tomography chest, confirming multiple territories of in situ thrombosis. DISCUSSION: COVID-19-related inflammatory cytokine release has been linked to activation of coagulation pathways. Marked elevation of ferritin and C-reactive protein levels in both patients were consistent with evidence of a hyperinflammatory state with 'cytokine storm'. Furthermore, the finding of elevated D-dimer levels lends support to the altered coagulation cascade that plausibly explains the multisystem thrombosis observed in our patients. The direct viral endothelial involvement and subsequent endothelial dysfunction may play an important role in the development of thrombosis in different vascular beds, as seen in our patients.
RESUMO
Arterial thrombosis and especially coronary thrombosis are known complications of cocaine abuse. We report three cases of severe life-threatening coronary arterial thrombosis manifesting as acute coronary syndromes. Thrombosis occurred predominantly in the proximal coronary tree with spontaneous distal embolization. The thrombotic occlusions were frequently not superimposed on flow-limiting atherosclerotic lesions. Treatment of these patients with thrombolytic, antithrombotic and anti-platelet therapy resulted in thrombus and symptom resolution. While stenting these vessels can be successfully executed and may be required in some cases of ST-elevation myocardial infarction, it may expose these patients to the risk of stent thrombosis, which is reported to be significantly higher than the risk of the general population.
