We describe an alternative procedure to treat the patient underwent aortic valve replacement with lesion of the right ventricle caused by tenacious mediastinalepicardial adhesions COVID-19 related. This alternative procedure is performed in two steps. In the first step is useful only to repair the right ventricle and in the second step, after 10 days, to proceed with aortic valve replacement/repair. This is important to avoid clamping the aorta which can cause ischemia of the repaired tissue, long CEC times with additional risk for the patient and to allow the stabilization of the patient in intensive care.
Keywords: COVID-19; SARS-COV-2; Pericardial Patch; Right Ventricle Injury
Although SARS-CoV-2 infection primarily targets the respiratory system [1,2], cardiac complication is the most common comorbidity. Several studies from China reported acute cardiac injury in 7.2% to 27.8% among hospitalized patients [3-5]. Some of the cardiovascular complications of COVI- 19 include STelevation myocardial infarction , myocarditis , cardiogenic shock, arrhythmias, pericardial effusions, cardiac tamponade  and infective endocarditis . We report the case of a patient who developed COVID-19 endocarditis and myocarditis with the development of tenacious mediastinal-epicardial adhesions responsible for injury to the right ventricle treated with pericardial patch in two steps.
Informed consent was obtained by the patient. Consent from the institutional review board was waived, being a clinical case. A 46-year-old male was referred to our hospital with progressive shortening of breath of recent onset. Transthoracic echocardiography revealed bicuspid aortic valve with moderate insufficiency and ascending aortic aneurysm with a maximum diameter of 55mm. No coronary artery disease was found at the angiogram. The patient underwent replacement of the ascending aortic with aortic valve repair (subcommisural annuloplasty). The postoperative course was uneventful and the patient was discharged home. Transthoracic echocardiography showed ejection fraction of 55% and mild aortic valvular insufficiency. After a day the patient performed COVID-19 molecular swab test resulted positive with mild symptoms: fever (37.5°C), mild dyspnea, changes in taste. Two months later the patient was readmitted because of progressive dyspnea (NYHA class III). Transthoracic echocardiogram showed severe aortic valve insufficiency. Transesophageal echocardiogram confirmed severe aortic valve insufficiency with prolapse of the non-coronary cusp and vegetation on both cusps.
The patient was referred for redo surgery of aortic valve replacement with mechanical prosthesis. At reoperation, the approach was through median sternotomy after cardiopulmonary bypass instituted by cannulation of the right femoral artery and vein. The surgery was complicated in the first phase by laceration of the right ventricle due to very tenacious mediastinal-epicardial adhesions from pericarditis caused by COVID-19. The patient underwent repair of the right ventricle with bovine pericardium patch (Figures 1 & 2). After discussion in heart team (cardiac surgeon, cardiologist and cardioanesthesiologist) it was decided to postpone the aortic valve replacement. The patient was transferred to intensive care. Ten days later the patient underwent aortic valve replacement with mechanical prosthesis (Sorin Bicarbon 25mm). The postoperative course was uneventful and the patient was discharged home in NYHA class I. Transthoracic echocardiography showed ejection fraction of 45%. After one year the patient was in NYHA class I with aortic prosthesis in place without periprosthetic leaks and vegetations.
This is a rare case reported in the literature of endocarditis and myocarditis caused by COVID-19 characterized by very tenacious mediastinal-epicardial adhesions. More attention is needed during the reopening of patients with previous COVID-19 because, despite the start of CEC and the empting of the right cardiac section, the risk of injury of the right ventricle is very high. When it happens, we suggest to proceed in two steps. In the first step is useful only to repair the right ventricle and in the second step, after 10 days, to proceed with aortic valve replacement/repair. This is important to avoid clamping the aorta which can cause ischemia of the repaired tissue, long CEC times with additional risk for the patient. In conclusion the message to take home is not to underestimate the tenacious adhesions from CVID-19 related myocarditis and, in case of laceration of the right ventricle, proceed in two steps to allow the stabilization of the patient in intensive care.
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