A case series of precipitous cardiac tamponade from suspected perimyocarditis in COVID-19 patients

Abstract

A 71-year-old well controlled hypertensive female presented on day 4 of acute COVID-19 illness with atypical chest pain and worsening exertional dyspnea. On examination, heart rate was 110 beats/min, blood pressure was 125/82 mmHg and there were decreased heart sounds with visible jugular venous distention. She was not in respiratory distress at rest and was not requiring supplemental oxygen. Chest radiography showed bilateral diffuse opacities (Figure 1). transthoracic echocardiography (TTE) confirmed a moderate pericardial effusion with right ventricular systolic compression, paradoxical right ventricular septal motion, end-diastolic right atrial collapse, and a plethoric inferior vena cava (IVC) with no respiratory variation. Her ejection fraction (EF) was 55%. Initial workup revealed mildly elevated troponin T levels of 0.14 ng/mL, NT-Pro BNP of 2 500 pg/mL. Initial EKG showed a low voltage sinus rhythm without ischemic features (Figure 2). Given the patient’s hemodynamic stability, echocardiographic lack of right ventricular collapse and posterior location of maximal effusion, she was initially managed medically with intent to consider surgical pericardial window if there was no improvement. Intravenous fluids, high dose aspirin, colchicine, and systemic steroids were initiated. However, over the ensuing 12 h the patient developed worsening hypotension with development of a friction rub on examination. Repeat EKG then showed diffuse ST elevation most prominent in the anterior and lateral leads (Figure 3). Serial biomarkers showed a rising troponin T to 1.5 ng/mL with developing lactic acidosis. Point-of-care echocardiography revealed a worsening pericardial effusion, severely impaired right ventricular (RV) function, end diastolic collapse of the right atrium, and a newly reduced EF of 30%−35% with global hypokinesis (Video 1). The interventional cardiology team was called for emergent pericardiocentesis however prior to intervention the patient went into cardiac arrest with pulseless electrical activity. The return of spontaneous circulation was achieved after three cycles of advanced cardiac life support (ACLS) and emergent bedside subxiphoid pericardiocentesis with a total of 200 mL of fluid removed. Repeat bedside echocardiography showed resolution of the effusion and an EF of 5%−10%. Soon afterwards the patient had another cardiac arrest, refractory to optimal ACLS, and expired within 24 hours of presentation. A 51 year old obese, hypertensive, African American female presented with pleuritic chest pain and worsening dyspnea on exertion. She had been on