Acute pulmonary embolism in conjunction with intramural right ventricular thrombus in a SARS-CoV-2-positive patient.

We were presented with a 60-year-old SARS-CoV-2- (Covid-19) positive gentleman who was transferred to our intensive care unit from a district general hospital. The patient was intubated and required mechanical ventilation prior to transfer for type 1 respiratory failure secondary to pneumonitis. His past medical history included hypertension and hypercholesterolaemia. Admission blood tests demonstrated markedly elevated troponin I of 593 ng/L and C-reactive protein of 360 mg/L. D-dimer levels were elevated at 32 228 ng/L. Bedside echocardiogram showed a dilated right ventricle (base 45 mm, mid 42 mm) with severely impaired right ventricular (RV) systolic function. Basal–mid RV free wall segments were akinetic, while apical segments were normokinetic (Panel A;Supplementary material online Video S1), suggestive of McConnell’s sign. Estimated pulmonary artery systolic pressure was 33 mmHg + right atrial pressures (Panel B1), and pulmonic valve acceleration time was 60 ms (Panel B2) indicative of the 60/60 sign. Combined, both signs are a sensitive marker for acute pulmonary embolism. Additionally, echo imaging showed a small, highly mobile mural thrombus within the RV free wall (Panel C;Supplementary material online Video S2). Subsequent CT pulmonary angiogram confirmed multiple filling defects in the inferior lingula (Panel D1) and in the segmental pulmonary artery branches to the lateral segment of the right middle lobe (Panel D2). The patient was thrombolysed and remains in intensive care.

Incoming data from China and Europe suggest that COVID-19 may be associated with a hypercoagulable state and increased risk for venous thrombo-embolism. An association between COVID-19 pneumonia and pulmonary emboli can be challenging for intensive care clinicians given the overlap in symptoms between both. We found bedside echocardiography (McConnell’s and 60/60 sign) to be sensitive in early detection of acute pulmonary embolism, which can aid management in COVID-19-positive patients.

(Panel A) Apical 4-chamber view. Akinetic right ventricular basal–mid free wall (yellow arrow) and normokinetic apical segments (red arrows) indicative of McConnell’s sign. We suggest watching Supplementary material online Video S1. (Panel B) The 60/60 sign is present when the pulmonary valve acceleration time is ≤60 ms and the tricuspid regurgitation pressure gradient is ≤60 mmHg. (Panel C) Small, highly mobile, right ventricular thrombus: red arrows. We suggest watching Supplementary material online Video S2. (Panel D) CT pulmonary angiogram showing bilateral pulmonary emboli: white arrows.

Supplementary data are available at European Heart Journal - Cardiovascular Imaging online.

Click here for additional data file.