Acute Cor Pulmonale in Critically Ill Patients with Covid-19
To rapidly communicate information on the global clinical effort against Covid-19, the Journal has initiated a series of case reports that offer important teaching points or novel findings. The case reports should be viewed as observations rather than as recommendations for evaluation or treatment. In the interest of timeliness, these reports are evaluated by in-house editors, with peer review reserved for key points as needed.
We describe five patients in our intensive care units (ICUs) who had confirmed Covid-19. All five patients presented to the ICUs between March 23 and April 4, 2020. Four of the five patients had profound hemodynamic instability and cardiac arrest with acute right ventricular failure, and one had severe hemodynamic instability without cardiac arrest. The clinical scenario and echocardiographic findings in one representative patient are provided (see the Video, available with the full text of this case at NEJM.org).
A 42-year-old man with a body-mass index (the weight in kilograms divided by the square of the height in meters) of 34 and a history of asthma presented to the hospital with hypoxemic respiratory failure and was admitted to the ICU for invasive mechanical ventilation. Testing to detect SARS-CoV-2 infection was positive. Other laboratory values on admission of this patient (Patient 1) are summarized in Table 1; these values were notable for normal levels of B-type natriuretic peptide, troponin, and d-dimer. The patient did not have a personal or family history of hypercoagulability and had received enoxaparin for prophylaxis against venous thromboembolism. Previous outpatient echocardiographic findings showed a normal biventricular size and function.
On ICU day 8, the patient became acutely hypotensive and had rapid progression to cardiac arrest with pulseless electrical activity. He received cardiopulmonary resuscitation with administration of epinephrine and intravenous thrombolytics, and spontaneous circulation returned. Echocardiography showed acute right ventricular dilatation with impaired systolic function (see Video), and subsequent computed tomography confirmed the presence of thromboembolism obstructing the left pulmonary artery.
Over a 48-hour period, five patients who were admitted to ICUs within our hospital system had profound hemodynamic instability due to the development of acute cor pulmonale (clinical details are summarized in Table 1). Cardiac arrest with pulseless electrical activity occurred in four patients, and three of these patients had died as of May 1. In one patient, acute cor pulmonale developed without cardiac arrest; this patient’s condition improved with thrombolytic therapy. At the time of hemodynamic instability, one patient was receiving therapeutic anticoagulation with intravenous heparin according to a non–citrate-based anticoagulation protocol, and the remaining patients were receiving prophylactic anticoagulation.
Myocardial dysfunction and hypercoagulability have been reported in patients with Covid-19; however, the true incidence and clinical implications of these events remain unclear.1-3 Although acute pulmonary thromboembolism was the most likely cause of right ventricular failure in these patients, this was not definitively confirmed in all cases. Acute cor pulmonale causing obstructive shock should be included in the differential diagnosis in critically ill patients with Covid-19.4,5 The role of thrombolytics and advanced management options such as extracorporeal life support for hemodynamic instability or cardiac arrest requires further investigation.
Christina Creel-Bulos, M.D.
Maxwell Hockstein, M.D.
Neha Amin, M.D.
Samer Melhem, M.D.
Alexander Truong, M.D., M.P.H.
Milad Sharifpour, M.D.
Emory University, Atlanta, GA
Disclosure forms provided by the authors are available with the full text of this case at NEJM.org.
This case was published on May 6, 2020, at NEJM.org.