Complications of Late-Presenting Myocardial Infarction in a COVID-19 Patient

A 44-year-old man with obesity and hypertension presented with dyspnea and cough during the coronavirus disease 2019 (COVID-19) pandemic. He was hypoxic and tested positive for COVID-19. Electrocardiogram showed sinus tachycardia with anteroseptal infarct of unknown age (Fig. 1A). Computed tomography (CT) showed multifocal pneumonia (Fig. 1B). Troponin was 0.09 ng/mL (peak 0.12 ng/mL). A systolic murmur was heard, and echocardiogram showed decreased ejection fraction, left ventricular (LV) aneurysm, pericardial effusion, and a ventricular septal defect (VSD) with left-to-right shunt (Fig. 1C, Video 1). Cardiac magnetic resonance imaging and CT (Fig. 1D–F, Video 2) showed infarction of the mid to apical septum and the LV apex, with pericardial effusion, apical aneurysm, and restrictive VSD with Qp/Qs of 2.2. The VSD was too large for percutaneous closure. After discussion, the heart team decided to postpone the surgery until after resolution of the COVID-19-related pneumonia. Pre-operative left heart catheterization showed occluded left anterior descending (LAD) artery and left-to-right shunt on ventriculography (Fig. 1G, Video 3). Finally, two months after initial presentation, the patient received bovine pericardial patch repair of the VSD (Fig. 1H), and LV aneurysm resection and LV reconstruction with the Dor procedure (Fig. 1I–J, Video 4).

Fig. 1.

(A) Electrocardiogram showing anteroseptal infarct. (B) CT showing multifocal pneumonia. (C) Echocardiogram demonstrating VSD with left-to-right shunt. (D) MRI with gadolinium enhancement demonstrating apical infarction and aneurysm. (E) MRI demonstrating VSD. (F) Cardiac CT demonstrating VSD and apical aneurysm. (G) Left heart catheterization demonstrating VSD. (H, I) Surgical image of aneurysm resection and repair of VSD (white arrow). (J) Left ventricular reconstruction with Dor procedure. CT, computed tomography; VSD, ventricular septal defect; MRI, magnetic resonance imaging.

A 44-year-old man with obesity and hypertension presented with dyspnea and cough during the coronavirus disease 2019 (COVID-19) pandemic. He was hypoxic and tested positive for COVID-19. Electrocardiogram showed sinus tachycardia with anteroseptal infarct of unknown age (Fig. 1A). Computed tomography (CT) showed multifocal pneumonia (Fig. 1B). Troponin was 0.09 ng/mL (peak 0.12 ng/mL). A systolic murmur was heard, and echocardiogram showed decreased ejection fraction, left ventricular (LV) aneurysm, pericardial effusion, and a ventricular septal defect (VSD) with left-to-right shunt (Fig. 1C, Video 1). Cardiac magnetic resonance imaging and CT (Fig. 1D–F, Video 2) showed infarction of the mid to apical septum and the LV apex, with pericardial effusion, apical aneurysm, and restrictive VSD with Qp/Qs of 2.2. The VSD was too large for percutaneous closure. After discussion, the heart team decided to postpone the surgery until after resolution of the COVID-19-related pneumonia. Pre-operative left heart catheterization showed occluded left anterior descending (LAD) artery and left-to-right shunt on ventriculography (Fig. 1G, Video 3). Finally, two months after initial presentation, the patient received bovine pericardial patch repair of the VSD (Fig. 1H), and LV aneurysm resection and LV reconstruction with the Dor procedure (Fig. 1I–J, Video 4).

The COVID-19 pandemic has presented a barrier in both seeking and delivering care for life-threatening illnesses. This case demonstrates the complications of late-presenting myocardial infarction and highlights the role of multimodality imaging and multidisciplinary team discussion in diagnosis and treatment of post-infarction VSD and ventricular aneurysm.

The following are the supplementary data related to this article.

Video 1

Echocardiogram demonstrating VSD with left to right shunt. VSD, ventricular septal defect

Video 2

MRI demonstrating VSD. VSD, ventricular septal defect

Video 3

Left heart catheterization demonstrating VSD. VSD, ventricular septal defect

Video 4

Left ventricular reconstruction with Dor procedure.

Supplementary data to this article can be found online at https://doi.org/10.1016/j.carrev.2021.04.016.

Declaration of competing interest

Gaby Weissman – No personal disclosures. Director of an academic cardiac computed tomography core lab with institutional contracts with Ancora Heart and LivaNova.

Toby Rogers – Proctor and Consultant: Medtronic, Edwards Lifesciences; Advisory Board: Medtronic; Equity interest: Transmural Systems.

Ron Waksman – Advisory Board: Abbott Vascular, Amgen, Boston Scientific, Cardioset, Cardiovascular Systems Inc., Medtronic, Philips, Pi-Cardia Ltd.; Consultant: Abbott Vascular, Amgen, Biotronik, Boston Scientific, Cardioset, Cardiovascular Systems Inc., Medtronic, Philips, Pi-Cardia Ltd., Transmural Systems; Grant Support: AstraZeneca, Biotronik, Boston Scientific, Chiesi; Speakers Bureau: AstraZeneca, Chiesi; Investor: MedAlliance; Transmural Systems.

All other authors – None.