ABSTRACT
The Covid-19 pandemic has
brought numerous impacts to cardiovascular surgery services, directly affecting
the management of patients. We report a case of a 68-year-old patient who
underwent coronary artery bypass graft surgery (CABG), who evolved on the 3rd
postoperative day with clinical and radiological worsening, requiring
mechanical ventilation and returning to the intensive care unit. The diagnosis
of Covid-19 infection was performed, being kept in a specific unit for clinical
management. On the 12th postoperative day, he evolved with hemodynamic
instability and death. Many questions remain about the impact of Covid-19 on
cardiovascular patients, and it is essential to understand this relationship
and its short- and long-term consequences.
Keywords: Pandemic; Covid-19;
Coronary heart disease
INTRODUCTION
In December 2019, in the city of Wuhan, Hubei
Province, China, an epidemic began that in a few months, became a global
pandemic. Infection by (SARS-CoV-2), which causes Covid-19 cases, has a
variable spectrum, from asymptomatic to severely symptomatic. The main symptoms
are fever, myalgia, headache and dyspnea, where some patients even with mild
symptoms may show reduced oxygen saturation levels¹.
In Brazil, preliminary data from the
beginning of the pandemic showed a mortality of 4%, where 90% of deaths
occurred in patients over 60 years of age, and of these, 51% had cardiovascular
disease. The complications of Covid-19 in this group of patients are
multifactorial, with numerous presentations, including arrhythmias, myocarditis
and shock².
Different observational studies have
described the impact of Covid-19 infection in patients undergoing coronary
artery bypass graft surgery (CABG) and other associated procedures. Mortality
may vary depending on the clinical conditions of the patients analyzed,
however, there is high prevalence of complications in this group of
individuals, including sepsis, longer mechanical ventilation and renal
dysfunction. It should also be noted that in the postoperative context, the
diagnosis can be challenging4-6.
Thus, we present a case of a patient with
multivessel coronary disease undergoing coronary artery bypass graft surgery,
who developed respiratory failure in the postoperative period in the intensive
care unit and was diagnosed with Covid-19 pneumonia.
Case
presentation
A 68-year-old male patient with a
history of systemic arterial hypertension and dyslipidemia was referred to a referral
service in cardiovascular surgery for invasive stratification after acute
coronary syndrome without ST- segment elevation. Admission
electrocardiogram with sinus rhythm, right bundle branch block and left
ventricular overload. Preoperative echocardiogram with preserved ejection
fraction (65%), without valvular dysfunction. Carotid Doppler without
significant stenosis with preserved vertebral flow.
Coronary angiography lesion of 70% in the
distal third of the right coronary artery, 70% in the anterior descending
artery as well as the circumflex artery. Ventriculography demonstrating
preserved contractile force. In addition, the patient had an RT-PCR test for Covid-19
performed using a negative oropharyngeal swab, collected four days before the
surgical procedure, as a protocol of our Institution for each patient scheduled
for surgery. The patient was not vaccined against Covid-19.
Patient underwent myocardial
revascularization surgery, median sternotomy was performed, with
cardiopulmonary bypass and intermittent clamping. The surgical team used the
left internal mammary artery (LIMA) for the anterior descending artery (LAD),
and use of the great saphenous vein for the posterior descending of the right
coronary artery (RCA) and the circumflex artery, without intraoperative
complications. The CPB and clamping time were 125min and 65min respectively. As
hemotherapy support, 12 grams of aminocaproic acid were used, being referred to
the ICU.
In the intensive care unit, he progressed
without the need for vasoactive drugs, being extubated in the first hours after
the surgical approach (Figure 1). He was discharged to the infirmary on the 2nd
postoperative day, being readmitted to the intensive care unit after 24 hours,
with a reduced level of consciousness and desaturation, requiring mechanical
ventilatory support. Laboratory tests (Table 1), cultures, radiography (Figure
2) and chest tomography were requested, showing a peripheral ground-glass
pattern on CT (Figure 3).
Table 1 - Evaluation of complementary exams
|
|
1°DPO
|
3°DPO
|
6°DPO
|
10°DPO
|
|
Hemoglobin (g/dL)
|
10
|
8,5
|
8,5
|
9,0
|
|
Hematocrit (%)
|
28,6
|
24,9
|
26,7
|
27,3
|
|
Leukocytes (10³/mm3)
|
13,25
|
8,03
|
10,86
|
18,38
|
|
Neutrophils (10³/mm3)
|
10,87
|
7,63
|
9,01
|
16,01
|
|
Lymphocytes
(10³/mm3)
|
1,59
|
0,16
|
1,30
|
0,92
|
|
Platelets
(10³/mm3)
|
89
|
98
|
215
|
302
|
After discussion with the Hospital's
infectology team, it was decided to start corticosteroid therapy,
piperacillin/tazobactam associated with teicoplanin empiric and prophylatic
enoxaparin with respiratory isolation, due to the hypoxemia and pattern of the
imaging tests presented. A new RT-PCR requested at readmission confirmed the
diagnostic hypothesis of the Covid-19 assistant team, with the patient being
referred to the specific ICU. It is observed that the blood cultures and
urocultures collected were negative.
Figure 1 – Chest
radiography on the 1st postoperative day with normal aspect
Figure 2 – Chest radiography on
the 3rd postoperative day demonstrating bilateral lung opacities
Figure 3 –
Computed Tomography of the Chest axial view on the 3rd postoperative day showing a peripheral
ground-glass pattern, especially in the right lung
On the 6th postoperative day, the respiratory pattern worsened. In the ICU, he
continued with sedation, without the need for vasoactive drugs, with
neuromuscular blockade for better coupling to the mechanical ventilator and
subfebrile episodes. On the 12th postoperative day, he evolved with hemodynamic
instability requiring vasoactive drugs, worsening renal function and lactate
levels, as well as significant abdominal distension, evolving to
cardiorespiratory arrest, not returning to spontaneous circulation after
measures instituted by the assistant team, following ACLS protocols.
DISCUSSION
In March 2020, the WHO officially declared the Covid-19
pandemic. SARS-CoV-2 is similar to SARS-CoV and MERS-CoV, responsible for
infections that occurred in China in the early 2000s and in the Middle East in
2012, respectively. However, with greater population dissemination capacity
compared to previous viruses1-2.
Studies published at the beginning of the pandemic
revealed that patients infected with Covid-19, who required an intensive care
unit for clinical management, had more comorbidities such as systemic arterial
hypertension and diabetes mellitus, as well as high mortality rates.
Cardiovascular complications also emerged, including myocarditis, arrhythmias,
acute coronary syndrome and thromboembolism³.
Similarly, coronary artery disease appears as a factor
that corroborates the morbidity of these patients, especially in those who need
a surgical approach. Several case series have been published in the literature
with the aim of understanding the relationship between Covid-19 infection and
CABG surgery. Cerillo et al4, in an analysis of 18 patients
undergoing cardiovascular surgery, 7 patients developed atrial fibrillation in
the postoperative period and 2 required re-approach due to bleeding. Another 2
patients had worsening renal function and 3 required inotropic support.
Surprisingly, there were no deaths in the sample described by the authors.
On the other hand, Fattouch et al5, in a
description of 20 cases in Italy, observed the presence of symptoms in 7
patients (35%), with a mean age of 71 years. Most patients had systemic
arterial hypertension and a mean EuroScore II of 3. Deaths were described in 3
(16.6%) of the sample. Another point to note refers to the reduced levels of
lymphocytes in patients who died, as well as high neutrophil counts. The
systemic inflammatory response produced by cardiopulmonary bypass itself can
trigger an acute respiratory syndrome in some cases, being a confounding or
contributing factor in Covid-19 infections.
In Brazil, the impact of Covid-19 on patients
undergoing coronary artery bypass graft surgery was
evaluated by Meija et al6, who demonstrated, in 15 patients
operated on with Covid-19, longer mechanical ventilation, pneumonia,
reintubation, pulmonary thromboembolism and sepsis . Mortality was evidenced in
7 patients (46.7%).
In the present case we can verify the alterations in
the levels of neutrophils, markedly elevated as well as lymphopenia. In line
with the changes in the blood count, the markedly rapid clinical evolution and
radiological worsening was evident in this report.
CONCLUSION
In summary, Covid-19 infection has an important impact on patients
undergoing cardiac surgery. The presence of comorbidities such as systemic
arterial hypertension are associated with worse outcomes. In addition, the
inflammatory condition produced by the Covid-19 infection associated with the
use of cardiopulmonary bypass can act synergistically, as discussed in some
studies.
In this way, the definition and maintenance of preoperative protocols and
organizational flows, despite the vaccines already available, will be
fundamental for the surgical activity and protection of our patients,
especially at a time when new peaks of infection are emerging in the face of
need for surgical treatment of patients.
Protection of humans and
animals
The authors declare that the
procedures were followed according to the regulations established by the
Clinical Re-search and Ethics Committee and to the 2013 Helsinki Dec-laration
of the World Medical Association.
Data confidentiality
The authors declare having
followed the protocols in use at their working center regarding patients’ data
publication.
Competing interests
The authors have declared
that no competing interests exist.
Funding sources
No subsidies or grants
contributed to this work.
Patient consent
Ethical approval was
obtained by The local Committee on Ethics and Research.
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