<div>Title: Experience with Circulatory Arrest for an Acute Aortic Syndrome
in a Covid 19 Patient</div><div>Running Head: Circulatory Arrest and Covid</div><div>John M. Trahanas MD, Asishana A. Osho MD, MPH, Jordan P. Bloom, MD, MPH
and George Tolis Jr., MD</div><div>Department of Surgery, Division of Cardiac Surgery, Massachusetts
General Hospital, 55 Fruit Street, Boston MA 02114</div><div>No disclosures or conflicts of interest</div><div>This was not a study so IRB approval was not applicable, and no study
consent was needed. Informed consent was obtained from patient in the
usual fashion via paper institutional procedural consent form.</div><div>Corresponding Author:</div><div>John M. Trahanas MD</div><div>Massachusetts General Hospital, Cox 630</div><div>55 Fruit Street, Boston MA 02114</div><div>T: 201-618-2179</div><div>F:</div><div>Jtrahanas@partners.org</div><div>Word Count-1076</div><div>Abstract-</div><div>The physiology of Covid 19 and its interaction with common medical
conditions and procedures is only beginning to be understood. We present
a case of a woman with an acute aortic rupture who required
cardiopulmonary bypass with deep hypothermic circulatory arrest. She had
no respiratory issues related to Covid, but her post op course was
notable for refractory status epilepticus and it is unclear if Covid 19
may have had played a role in exacerbating neurologic injury.</div><div>Introduction-</div><div>The COVID-19 pandemic has affected every facet of life around the world
and has placed an enormous burden on the delivery of healthcare.
Although much about this illness has been discovered over the past few
months, its potential effect on recovery from cardiopulmonary bypass
remains unstudied. We present a case of emergent repair of an ascending
aortic rupture requiring circulatory arrest in a patient with COVID-19
infection.</div><div>Case Report-</div><div>The patient is a 69-year-old woman with a past medical history notable
only for remote endovascular embolization of an intracerebral aneurysm.
She presented to an outside hospital after syncope while grocery
shopping. On arrival she was hypotensive and tachycardic, and a CT scan
of the chest demonstrated a free aortic rupture with an associated
intramural hematoma in the ascending aorta as well as a large
pericardial effusion (Figure 1). Aortic arch anatomy was normal. After
partial resuscitation she was transferred to our institution. Despite
denying dyspnea, fevers, cough or any other symptoms suspicious for
viral illness, she tested positive for COVID-19 via nasal swab PCR at
the outside facility, and we were notified of this result as she was
en-route to our center. He CT did not demonstrate any infiltrates
suspicious for viral infection.</div><div>On arrival the patient was mentating, but mottled and hemodynamically
unstable requiring norepinephrine 50 mcg/min to maintain a systolic
blood pressure of 60 mmHg. Given her presentation, she was emergently
taken to the operating room. The patient was prepped and draped awake,
and cardiopulmonary bypass was established via the femoral vessels prior
to induction of anesthesia. After successful intubation, the chest was
entered. Large amounts of mediastinal blood and clot were evacuated and
the rupture site was controlled with packing behind the base of the
ascending aorta. Cooling was immediately initiated and the ascending
aorta was replaced with a 24 mm woven vascular tube graft under deep
hypothermic circulatory arrest at 18 degrees Celsius. No antegrade or
retrograde cerebral perfusion was used. Circulatory arrest time was 26
minutes, and total cardiopulmonary bypass time was 161 minutes. The
patient separated from bypass with minimal inotropic support, displayed
no significant coagulopathy and had no difficulty with oxygenation or
ventilation. Postoperatively, the patient remained on minimal ventilator
settings (30% FiO2 and PEEP 5) with an unremarkable chest radiograph
(Figure 2). Her barrier to extubation, however, was seizure activity
documented by continuous electroencephalogram monitoring which required
four anti-epileptic agents in order to achieve suppression. Multiple
head CT scans were unrevealing, and MRI of the brain showed only
punctate micro-hemorrhages that our neurologists felt were related to
her aortic operation and likely not causative of her seizures. She
eventually regained a normal mental status and a non-focal neurological
examination and was discharged to a long-term care facility.</div><div>Comment</div><div>We believe that this case represents the first reported successful
repair of a free aortic rupture in a COVID-19 positive patient. This
patient presented in extremis and required emergency surgical therapy in
accordance with the recently published triage guidelines related to
COVID-19 status<sup>1</sup> .</div><div>An aortic center in the United States has reported a similar case of
aortic dissection in a patient who was suspected (but not confirmed) to
be COVID-19 positive prior to admission<sup>2</sup>. The patient
was repaired in a similar manner as ours, but unfortunately developed
respiratory failure and progressive multi system organ failure
postoperatively, ultimately leading to their demise. Our patient did not
show any evidence of postoperative respiratory dysfunction despite their
known COVID-19 infection.</div><div>Our patient did suffer considerable morbidity due to status epilepticus.
While we have no definite evidence that seizures were a result of Covid
in this patient, there are reports in the literature of COVID-19
invading the central nervous system and subsequently causing neurologic
injury manifesting as seizures<sup>3</sup>. It may be that the
known deleterious effects of cerebral ischemia, despite hypothermia,
meticulous deairing and acid/base management during cardiopulmonary
bypass may be exacerbated by viral-mediated neurologic injury. Based on
our single-case experience we recommend surgeons remain vigilant for
seizure activity in these patients.</div><div>Finally, is it possible that COVID-19 predisposes patients to developing
acute aortic syndromes? The anecdotal decrease in the number of patients
presenting to hospitals with acute aortic pathologies during this
pandemic would suggest not, but this is thought to be due to the
reluctance of symptomatic patients to seek care for fear that they will
contract COVID-19 at the hospital. There is data showing that patients
with influenza can develop inflammatory states that may promote acute
vascular events such as myocardial infarction<sup>4</sup>. It
remains to be seen if a pattern of aortic and vascular injury develops
as the Covid pandemic progresses.</div><div>Figure 1-</div><div>Sagittal CT image demonstrating a contained aortic rupture with
intramural hematoma as well as pericardial tamponade</div><div>Figure 2-</div><div>Post-Operative Day 2 portable Chest X-Ray without evidence of
infiltrates</div><div>REFERENCES</div><div>1. Haft JW, Atluri P, Alawadi G, et al. Adult cardiac surgery during the
COVID-19 Pandemic: A Tiered Patient Triage Guidance Statement. <i>Ann
Thorac Surg</i> . April 2020. doi:10.1016/j.athoracsur.2020.04.003</div><div>2. Fukuhara S, Rosati CM, El-Dalati S. Acute Type A Aortic Dissection
during COVID-19 Outbreak. <i>Ann Thorac Surg</i> . April 2020.
doi:10.1016/j.athoracsur.2020.04.008</div><div>3. Asadi-Pooya AA. Seizures associated with coronavirus infections.<i>Seizure</i> . 2020;79:49-52. doi:10.1016/j.seizure.2020.05.005</div><div>4. Kwong JC, Schwartz KL, Campitelli MA, et al. Acute Myocardial
Infarction after Laboratory-Confirmed Influenza Infection. <i>N Engl
J Med</i> . 2018;378(4):345-353. doi:10.1056/NEJMoa1702090</div>