Unexpected stormy course after uneventful device closure of atrial septal defect - Possibly due to post-COVID-19 inflammatory state

Abstract

COVID-19 infection has myriad manifestations from self-limiting illness to stormy multi-organ failure. A 28-year-old woman negative for COVID reverse transcription-polymerase chain reaction underwent an uneventful elective device closure of atrial septal defect on intubation anesthesia. While a brief postprocedural endotracheal bleed was noted, significant hypoxia and respiratory distress ensued after extubation with biventricular dysfunction, pleural effusion, and radiographic evidence of acute respiratory distress syndrome. COVID antibodies were positive, and inflammatory markers were elevated. After a conservative multipronged medical management including anticoagulation, antibiotics, aspirin, beta-blocker, diuretics, and sildenafil, she improved in 1 week. The clinical course during this pandemic era gives a possibility of a post-COVID inflammatory syndrome as a potential etiology.

Keywords: Acute respiratory distress syndrome; COVID antibody; multisystem inflammation; transcatheter intervention.

Figure 1

Echocardiogram in subcostal (a) and apical four-chamber view (b) showing secundum atrial septal defect (yellow arrow) with a thin aneurysmal inferior margin

Figure 2

Chest X-ray in posterior–anterior view during (a) Preprocedure showing cardiomegaly and increased pulmonary blood flow. (b) Postprocedure after endotracheal bleeding showing haziness in the left upper zone. (c) CXR on day 3 during acute deterioration, showing increased bilateral hilar congestion with perihilar consolidation and bilateral pleural effusion. (d) Predischarge CXR in the resolution phase. CXR: Chest X-ray

Figure 3

Echocardiogram in (a) subcostal view showing right pleural effusion (red arrow). On the third postprocedure day after the deterioration (b) parasternal short axis view and (c) and apical four-chamber view showing dilated right ventricle. Predischarge echocardiogram showing (d) reduced right pleural effusion (green arrow). Predischarge echocardiogram in parasternal short axis view (e) and (f) apical four-chamber view showing reduction of the RV dilatation and stable device position. RV: Right ventricle

Figure 4

Computed tomographic scanning of the chest in (a) axial, (b) frontal view showing evidence of pleural effusion (yellow arrow), lung collapse and features suggestive of pulmonary edema. The atrial septal occluder is marked with red arrow (a) CT pulmonary angiogram in sagittal and axial view showing dilated right ventricle (c), dilated pulmonary artery with no evidence of thrombus (d) and significant pleural effusion in the right side (yellow arrow). CT : Computed tomography