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\begin{document}

\title{Large tricuspid valve thrombus complicating COVID-19 pneumonia}



\author[1]{Yasser Kamal}%
\author[1]{Shady E. Al-Elwany}%
\author[1]{Mostafa M. ELsayed}%
\affil[1]{Minia University Faculty of Medicine}%


\vspace{-1em}



  
  \date{May 18, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
\textbf{Background:} Hemostatic disturbances with coronavirus disease
2019 (COVID-19) can predispose to tricuspid and right heart thrombi in
very rare instances. \textbf{Aim:} We describe a 29-year-old female
patient without previous cause of thrombosis who developed large
tricuspid valve thrombus (TVT) and moderate-to-severe tricuspid
regurgitation (TR) during the course of COVID-19 infection.
\textbf{Materials and methods:} Persistant fever and tachycardia with
thrombocytopenia and high D-dimer increased the index of suspicion. The
diagnosis was made by bedside transthoracic echocardiography (TTE) and
cardiac magnetic resonance (CMR). Surgery was performed for thrombectomy
and tricuspid valve replacement with a tissue valve. \textbf{Discussion
and conclusion:} Detection of TVT in COVID-19 patients on the basis of
high index of suspicion, bedside TTE and non-invasive CMR helps early
surgical treatment and subsequent reduction of mortality and hospital
stay.%
\end{abstract}%



\sloppy


\textbf{1. INTRODUCTION}

More than two years after the appearance of coronavirus disease 2019
(COVID-19), the relevant research is still ongoing. COVID-19 can lead to
hemostatic disorders and thrombotic diseases due to exaggerated
inflammatory process, decreased tissue oxygenation, and endothelial
dysfunction {[}1{]}.

Intracardiac thrombi, including tricuspid valve thrombus (TVT), are very
rare life-threatening complications of COVID-19 which indicate high
index of suspicion to provide early proper management {[}2, 3{]}.
Herein, we report a surgically treated patient with TVT associated with
moderate-to-severe tricuspid regurgitation (TR) during the course of
COVID-19 pneumonia.

\textbf{2. CASE REPORT}

A 29-year-old female patient presented with a 5-day history of fever,
palpitations, and dyspnea. There was no history of chronic illness,
trauma, surgery, or intravenous drug abuse. The patient had positive
polymerase chain reaction (PCR) test for COVID-19 followed by home
treatment and partial clinical improvement before re-occurence of fever
and shortness of breath.

On admission, she had fever (temperature of 38\selectlanguage{ngerman}°C), siuus tachycardia,
tachypnea, normal blood pressure, and oxygen saturation of 94\% in room
air. The laboratory investigations (Table 1) revealed total leucocytic
count of 12000/\selectlanguage{greek}μ\selectlanguage{english}L (lymphocyte count: 15\%) and C-reactive protein (CRP)
of 67.4 mg/L, with positive PCR test.

\textbf{2.1 Diagnostic workup}

During the hospital stay, the patient underwent diagnostic and
therapeutic workup as appropriate (Figure 1). High-resolution computed
tomography (HRCT) revealed multiple peripheral patchy ground glass
opacities at both lung fields associated with pneumonic consolidation
(Figure 2). The patient received the standard treatment of COVID-19
pneumonia with no need for mechanical ventilation.

Persistant fever and tachycardia with elevated D-dimer and
thrombocytopenia indicated bedside transthoracic echocardiography (TTE)
which revealed large mobile tricuspid valve mass, mostly thrombus,
measuring 33 x 17 mm and protruding into right atrium (RA) and right
ventricle (RV), with moderate-to-severe TR and moderate pulmonary
hypertension. Furthermore, cardiac magnetic resonance (CMR) showed TVT
of 28 x 21 x 11mm oscillating into the right ventricle with preserved
ventricular function (Figure 3). Blood culture showed no growth.

\textbf{2.2 Treatment}

To avoid thromboembolism, the patient underwent cardiac surgery through
median sternotomy. Intraoperatively, a mass attached to the septal
leaflet was identified with no other masses in RA and RV (Figure 4).
Beating heart removal of the mass followed by tricuspid valve
replacement with tissue valve \#31. Tissue culture showed no growth.

\textbf{2.3 Outcome}

The postoperative course was uneventful except for delirium and
agitation on the 3\textsuperscript{rd} postoperative day that improved
on the medical treatment with the absence of any lesion on brain MR
study. The patient discharged home 17 days after surgery with negative
PCR test, and she continued on a regimen of antibiotic therapy and oral
anticoagulants. On follow-up visits, chest X-ray, TTE, and laboratory
investigations were normal with improved general condition.

\textbf{3. DISCUSSION}

Thromboembolic complications are reported in 27\% of COVID-19 patients
{[}1{]} with challenging diagnosis due to similarity of its clinical
manifestations and laboratory findings with the usual features of
COVID-19 infection. Thus, high index of clinical suspicion is
recommended in addition to emergency pulmonary angiography or
echocardiography in supected patients {[}4{]}. Our report describes a
rare case of large TVT in COVID-19 female patient during the third wave
of the pandmic. One previous report described a large
thrombus-in-transit through the tricuspid valve into the RV in adult
male {[}2{]}, and another report described a large TVT extended to the
RA and RV and attached to the tip of central venous catheter in a child
{[}3{]}.

Our patient had unremarkable risk factors for thrombosis prior to
COVID-19 infection. The clinical, laboratory, and imaging workups to
distinguish thrombotic disease from COVID-19 infection are challenging
due to: 1) similar presentation of dyspnea, chest pain, tachypnea, and
tachycardia in patients with thrombosis or COVID-19; 2) routine use of
prophylactic anticoagulants in all COVID-19 patients; 3) usual elevation
of D-dimer and pro-inflammatory markers in both conditions; and 4)
limited mobility of COVID-19 patients which may delay the proper imaging
study to identify thrombotic diseases.

In our case, TVT was initialy detected on bedside TTE; however, TTE
could not differentiate thrombus from vegetation thus CMR was performed
for further evaluation. CMR has the ability to detrmine the acuity of a
thrombus and to differentiate it from cardiac tumors or other true
cardiac lesions {[}5{]}. Moreover, CMR has a specific role in COVID-19
patients to determine cardiovascular complications because of its high
accuracy in evaluation of myocardial structure, function, tissue
characterisation, and perfusion {[}6{]}.

The decision for surgery in our case aimed to avoid subsequent
complications of a large mobile thrombus (\textgreater{} 2 cm)
associated with moderate-to-severe TR. The treatment of TVT includes
medical therapy with anticoagulants or fibrinolytics, surgery, and
percutaneous directed retrieval. Each modality has its benefits and
risks {[}7{]}. Therefore, the treatment should be decided on indvidual
basis depending on size and dynamics of the thrombus, surgical fittness,
ventricular function, and hemodynamic stability {[}3, 8{]}.

\textbf{4. CONCLUSION}

COVID-19 is a predisposing factor of thromboembolic events. A bedside
TTE and CMR help accurate assessment of clinically suspected TVT. Early
surgical removal is efficient.

\textbf{ABBREVIATIONS}

CMR: Cardiac magnetic resonance; COVID-19: coronavirus disease 2019;
HRCT: High-resolution computed tomography; PCR: Polymerase chain
reaction; RA: Right atrium; RV: Right ventricle; TR: Tricuspid
regurgitation; TTE: Transthoracic echocardiography; TVT: Tricuspid valve
thrombus

\textbf{REFERENCES}

1. Klok FA, Kruip MJHA, van der Meer NJM, Arbous MS, Gommers DAMPJ, Kant
KM, Kaptein FHJ, van Paassen J, Stals MAM, Huisman MV, Endeman H.
Incidence of thrombotic complications in critically ill ICU patients
with COVID-19. Thromb Res. 2020;191:145-47.

2. Khan HMW, Khan MR, Munir A, Moughrabieh A, Changezi HU. A giant
right-heart thrombus-in-transit in a patient with COVID-19 pneumonia. Am
J Case Rep. 2020;21:e927380.

3. Bigdelian H, Sedighi M, Sabri MR, Dehghan B, Pourmoghaddas Z, Saleh
R, Sherafat A, Massoumi G, Rezaei MK, Shahbazi M. Right atrial thrombus
in a COVID-19 child treated through cardiac surgery. Front Cardiovasc
Med. 2020;7:579522.

4. Konstantinides SV, Meyer G, Becattini C et al., ESC Scientific
Document Group: 2019 ESC Guidelines for the diagnosis and management of
acute pulmonary embolism developed in collaboration with the European
Respiratory Society (ERS). Eur Heart J, 2020; 41(4): 543--603.

5. Johnson EM, Gage KL, Feuerlein S, Jeong D. Cardiac Magnetic Resonance
for the Evaluation of Suspected Cardiac Thrombus: Conventional and
Emerging Techniques. J Vis Exp. 2019;148:1-7.

6. Clark DE, Aggarwal SK, Phillips NJ, Soslow JH, Dendy JM, Hughes SG.
Cardiac Magnetic Resonance in the Evaluation of COVID-19. Card Fail Rev.
2022;8:e09.

7. Gunduz Y, Ucar A, Vatan MB, Keser N. Tricuspid valve thrombus causing
acute pulmonary embolism. BMJ Case Rep. 2013;2013:bcr2012006995.

8. Arumairaj AJ, Boma N, Mushiyev S, Morcos M, Habtes I. Infected Right
Ventricle Thrombus as a Cause of Persistent Sepsis. Cureus.
2020;12(10):e10751.

\textbf{Table (1):} Laboratory hematologic results during hospital stay
of the patient and at the first postoperative follow-up visit\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Test\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Reference range\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
At admission (26/1/2022)\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Before surgery (8/2/2022)\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
After surgery (15/2/2022)\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
At discharge (26/2/2022)\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
At follow-up (13/3/2022)\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Total leucocytic count (x 10\^{}3)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4-11\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
14.27\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
10.6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6.8\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6.5\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Red blood cell (x 10\^{}6)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4-5.5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
3.95\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4.2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4.2\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4.15\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4.35\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Hemoglobin (g/dl)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
12-16\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
10\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11.65\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11.1\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
10.7\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
11.8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Hematocrite (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
36-46\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
31.9\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
36.5\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
33.6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
32.6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
35.7\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Platelet count (x 10\^{}3)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
150-400\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
175\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
144\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
231\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
275\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
272\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Lymphocyte (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
25-45\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
15\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
19\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
30\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
26\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
35\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Neutrophil (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
45-75\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
80\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
78\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
60\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
65\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
55\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
CRP (mg/L)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textless{}6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
67.4\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
24\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
4\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
D-dimer (mg/L)\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0.19-0.52\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
1.40\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
2.30\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0.68\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0.50\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
0.46\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

CRP: C-reactive protein

\textbf{Figure 1:} Timline of in-hospital diagnostic and therapeutic
workup. TTE:Transthoracic echocariography, CMR: Cardiac magnetic
resonance, TV: Tricuspid valve. MR: magntic reonance. PCR: Polymrae
chain reaction.

\textbf{Figure 2:} Computed tomography of the chest shows consolidation
and peripheral ground glass lung opacitis (arrow).

\textbf{Figure 3:} Cardiac magnetic resonance shows tricuspid valve
thrombus (white arrows).

\textbf{Figure 4:} Intraoperative view of tricuspid valv thrombus
attached to septal leaflet (white arrow).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/1-Timeline/1-Timeline}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/2---Labelled/2---Labelled}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/3---Labelled/3---Labelled}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/4---Labelled/4---Labelled}

\end{center}
\end{figure}

\selectlanguage{english}
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