Life-Threatening Cardiac Tamponade Secondary to COVID-19 Treated with Uniportal Video-Assisted Thoracoscopic Surgery: A Case Report.

BACKGROUND The COVID-19 outbreak emerged in December 2019 in Wuhan, China. COVID-19 is caused by the SARS-CoV-2 coronavirus and mostly affects the respiratory system but can also affect other organs, including the cardiovascular system. Furthermore, the most common cardiac complications include severe left ventricular dysfunction, acute myocardial injury, and arrhythmias. Life-threatening cardiac tamponade and large pericardial effusion are exceedingly rare complications in patients recovered from COVID-19. Previously, this condition was treated with pericardiocentesis, colchicine, and corticosteroids. CASE REPORT We present the case of a 54-year-old man who recovered from a SARS-CoV-2 infection 7 days before presentation and describe a complicated pericardial effusion with life-threatening cardiac tamponade. To the best of our knowledge, this is the first case of pericardial effusion with cardiac tamponade that was successfully treated with single port or uniportal video-assisted thoracoscopic surgery with an excellent outcome. CONCLUSIONS Life-threatening cardiac tamponade with pericardial effusion is an exceedingly rare complication in patients recovered from COVID-19. Generally, patients diagnosed with pericardial effusion undergo a pericardiocentesis procedure. Although there are multiple treatment options for draining pericardial effusion, the recurrence rate with surgical pericardial window formation is the lowest. However, our patient underwent surgery using a uniportal video-assisted thoracoscopic surgery with an excellent outcome.

Background

The current COVID-19 outbreak emerged in December 2019 in Wuhan, China. It is caused by the SARS-CoV-2 coronavirus and mostly affects the respiratory system; however, it can also affect other organs, including the cardiovascular system. Severe left ventricular dysfunction, acute myocardial injury, and arrhythmias are the most prevalent cardiac consequences [1].

The most commonly documented cardiovascular symptoms of COVID-19 include acute coronary syndrome, cardiac arrhythmias, thrombosis, and myocarditis. Although pericardial involvement has been reported in patients with COVID-19, the exact prevalence is unknown [2]. In a comprehensive evaluation of 34 individuals from 33 studies who presented with pericarditis, it was shown that 35% had cardiac tamponade, nearly half had myopericarditis, and 76% had pericardial effusion [3]. Conversely, reports of life-threatening cardiac tamponade and large pericardial effusion are rare [4]. Previously, this condition was treated with pericardiocentesis, colchicine, and corticosteroids.

Here we present the case of a 54-year-old man who recovered from SARS-CoV-2 infection and developed complicated pericardial effusion with cardiac tamponade, which was life-threatening. To the best of our knowledge, this is the first case of pericardial effusion with cardiac tamponade that was successfully treated using a single port or uniportal video-assisted thoracoscopic surgery (u-VATS) approach with an excellent outcome.

Case Report

A 54-year-old man presented with a severe cough of a 2-month duration. His general medical history was not significant. The patient had been diagnosed with COVID-19 65 days before presentation and recovered 7 days before arrival to hospital, as confirmed by real-time polymerase chain reaction (RTPCR) testing.

Regarding the treatment of COVID-19, the patient had received 1 mg ceftriaxone injection every 12 h for 6 days, vitamin D supplement for 10 days, and dextromethorphan 30 mg syrup every 8 h for 9 days, followed by paracetamol and oxygen therapy.

Upon arrival, the patient’s vital signs were blood pressure of 72/64 mmHg (hypotensive), heart rate of 132 beats/min (tachycardia), respiratory rate of 31 breaths/min (tachypnea), temperature of 37.4°C, and oxygen saturation of 82% at rest without oxygen therapy. Laboratory test results were within normal limits apart from an increased white blood cell count, C-reactive protein level, and D-dimer level (). The troponin test was negative. Radiologically, a computed tomography (CT) scan showed small ground-glass opacity in the right upper lobe. In addition, a 12-lead electrocardiogram showed sinus tachycardia. Moreover, transthoracic echocardiography was performed in the relaxation phase and revealed pericardial effusion with features of cardiac tamponade (dilated right atrium with systolic right atrium collapse, diastolic right ventricle collapse, dilated and plethoric inferior vena cava with failure of the inspiratory collapse of the inferior vena cava to more than 50%) (Video ). The patient was free from any diseases, for example, connective tissue disorder, malignancy, endocarditis, myocarditis, and pericarditis. Finally, the patient was diagnosed with pericardial effusion, and cardiac tamponade secondary to COVID-19.

Subsequently, we planned to drain pericardial effusion with a wedge resection of the ground-glass-opacity through u-VATS. The patient was sent to undergo surgery under general anesthesia, and double-lumen endotracheal intubation was performed in the supine position. Then, the patient was positioned to the left lateral decubitus position and a 3-cm incision in the mid-axillary line in the fifth intercostal space was performed. The pericardium was full of fluid, and with a no. blade 15, we created a small pericardial window. An amount of 1200 cc of serosanguinous fluid was drained and tested negative for COVID-19 (Video ). Then, we did a wedge resection in the right-upper lobe with staplers. A single chest drain was placed, and the incision was sutured in layers. Fluid cytology was negative for malignant cells, an acid-fast bacilli smear was negative, and no growth on fungal and bacterial cultures was reported.

In conclusion, all vital signs of the patient were normal apart from intermittent decreasing blood pressure. After 3 days in the Restorative Care Unit, the patient was discharged home. He experienced no recurrence of pericardial effusion.

Discussion

SARS-CoV-2 is a new virus that causes COVID-19. Early studies in Wuhan, China, showed that patients with COVID-19 frequently develop fever, upper respiratory symptoms, and pneumonia [5]. However, the pericardial association has been rarely reported [6,7]. People who have pre-existing cardiovascular disease are more prone to develop serious illness and have a higher death rate [8]. The precise mechanism behind SARS-CoV-2-induced acute myocardial injury is unclear [9]; however, it might be related to a cytokine storm [10] or myocardial ACE2 receptors [11]. COVID-19 causes numerous cardiovascular complications including arrhythmia, myocarditis, acute myocardial injury, cardiogenic shock, and thromboembolism [12,13]. However, cardiac tamponade has rarely been reported as a COVID-19 complication [12-14].

Here, we report a case of a patient who recovered from COVID-19 with large symptomatic pericardial effusion causing life-threatening cardiac tamponade secondary to COVID-19. Pericardial effusion was reported in 4.55% of 2738 patients with COVID-19 [15]. To date, only a few cases of pericardial effusion causing cardiac tamponade in patients with COVID-19 have been reported in the literature, and all of them were treated by pericardiocentesis, colchicine, pericardial window, aspirin, ibuprofen, steroids, and antiviral drugs [9,14,16-33]. Conversely, our case report demonstrates the first case treated by u-VATS. Although there are multiple treatment options for draining pericardial effusion, the recurrence rate of the surgical window option is reported to be the lowest [34,35]. Pericardial effusion has been reported in pericarditis due to tuberculous, malignant tumors, uremia, collagen-vascular disorders, trauma, post-¬myocardial infarction, irradiation, and unknown etiology of pericarditis [36]. Our patient was free from any diseases, such as connective tissue disorder, malignancy, endocarditis, myocarditis, and pericarditis. Little is known about the association between hemorrhagic pericardial effusion and viral infections; however, it has been linked to the Coxsackie virus [37].

Due to large pericardial effusion and symptoms of cardiac tamponade, this patient, who arrived with tachycardia and developed shortness of breath, underwent u-VATS. In this case, 1200 mL of pericardial fluid was drained, revealing a nonhemorrhagic pericardial effusion. His overall health improved after the u-VATS approach. Further studies are required to evaluate the benefit of u-VATS in patients with pericardial effusion. Because of our experience with single-port or u-VATS technology, we believe we can manage even the most challenging cases, such as this one. U-VATS should only be done by skilled surgeons.

Conclusions

Life-threatening cardiac tamponade with pericardial effusion is an exceedingly rare complication in patients who have recovered from COVID-19. Generally, patients diagnosed with pericardial effusion undergo a pericardiocentesis procedure. However, our patient underwent a surgical u-VATS approach with an excellent outcome.

Table 1.

Patient’s preoperative laboratory test results.

Variables	Test result	Reference range
White blood cells	13000 cells/mcL	4500–11 000 cells/mcL
Red blood cells	5.1 million cells/mcL	4.5–5.9 million cells/mcL for men; 4.1–5.1 million cells/mcL for women
Platelets	250 000 platelets/mcL	150 000–450 000 platelets/mcL
Hemoglobin	16 g/dL	14–17.5 g/dL for men; 12.3–15.3 g/dL for women
Erythrocyte sedimentation rate	30 mm/h	0–22 mm/h for men; 0–29 mm/h for women
C-reactive protein	87 mg/dL	<10 mg/L
D- dimer	1273 ng/mL	<250 ng/mL
Vitamin D	21 ng/dL	20–40 ng/mL
Serum iron	76 mcg/dL	60–170 mcg/dL
Total iron binding capacity	310 mcg/dL	240–450 mcg/dL
Blood urea nitrogen	12 mg/dL	6–24 mg/dL
Serum creatinine	0.9 mg/dL	0.7–1.3 mg/dL for men; 0.6–1.1 mg/dL for women
Rheumatoid factor	11 IU/mL	Less than 14 IU/mL
Anticardiolipin lupus-anticoagulant	15 CU	Less than 20 CU for IgG, IgM, and IgA
Anti-Smith antibody	3 U/mL	0–7 U/mL
Antinuclear antibody (ANA)P-ANCAC-ANCA	Negative	Negative
HCV, Hbs, HIV antigen tests	Negative	Negative
Troponin test	Negative	Negative
Total serum bilirubin	0.6 mg/dL	0.1–1.2 mg/dL
Serum glutamic oxaloacetic transaminase	26 U/L	17–59 U/L
Alanine aminotransferase	19 U/L	0–35 U/L
Alkaline phosphate	87 IU/L	38–126 IU/L
Thyroid stimulating hormone	0.1 mIU/L	0.5–5.0 mIU/L
T3	67 ng/dL	60–180 ng/dL
T4	0.7 ng/dL	0.9–2.3 ng/dL
Serum electrolytes
Sodium	132 mEq/L	136–144 mEq/L
Potassium	4.1 mEq/L	3.7–5.1 mEq/L
Chloride	100 mEq/L	97–105 mEq/L
Calcium	4.6 mEq/L	4.4–5.2 mEq/L
Phosphate	0.98 mEq/L	0.87–1.55 mEq/L