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\begin{document}

\title{Left Ventricular Thrombus Formation in a COVID-19 Patient with a Complex
Course of Pericarditis and Myocardial Infarction.}



\author[1]{Jalil Golshani}%
\author[1]{Zahra Kalantari}%
\author[1]{Hassan Ahangar}%
\author[1]{Saman Ameri}%
\author[1]{Reza Madady}%
\author[1]{Vahid Khosroshahi}%
\affil[1]{Zanjan University of Medical Sciences}%


\vspace{-1em}



  
  \date{May 17, 2024}


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\textbf{Left Ventricular Thrombus Formation in aCOVID-19 Patient with a
Complex Course of Pericarditis and Myocardial Infarction.}

\textbf{Abstract:}

\textbf{Background:} Coronavirus Disease 2019 (COVID-19) has grown
significantly in scale as a result of the development of the novel
Zoonotic Severe Acute Respiratory Syndrome Coronavirus-2. Despite the
fact that respiratory symptoms predominate, cardiovascular problems have
also been reported. Pericarditis, inflammation of the pericardium, is
the most prevalent pericardial disease and a prominent cause of acute
chest discomfort in young people which is most commonly caused by viral
infections. Individuals with COVID-19 may be hypercoagulable, which
could accelerate the onset of left ventricular thrombus (LVT).

\textbf{Case Presentation:} A 38-year-old COVID-19 patient with ST
elevation MI and LV thrombus and the signs and symptoms of pericarditis
with no past medical history of any heart conditions was represented.

\textbf{Conclusions:} The case demonstrated that thrombotic
complications such as coronary thrombosis and LV clot could occur even
in COVID-19 patients with non-specific symptoms and gradually progressed
and led to clot formation and coronary involvement. This indicates the
mysterious face of COVID-19. This complex process highlights the
necessity of screening patients for COVID-19 disease even with
non-specific cardiac symptoms.

\textbf{KEYWORDS:} Pericarditis, Myocardial Infarction, Left Ventricular
Thrombus Formation, COVID-19

\textbf{Background:}

Pericarditis, inflammation of the pericardium, is the most prevalent
pericardial disease and a prominent cause of acute chest discomfort in
young people (1). It is mostly caused by viral infections as well as
rheumatic illnesses, uremia, or neoplasms (2). A pericardial friction
rub, concave ST-segment elevations, pleuritic chest discomfort, and
pericardial effusion are all common indications and symptoms (1). Given
that pericarditis is generally self-limited, the therapy is usually
supportive, including nonsteroidal anti-inflammatory medications or
colchicine. Other causes of pericarditis, on the other hand, may have
different prognosis and therapeutic implications (3, 4).

Up to 15\% over all acute myocardial infarction (AMI) patients and 25\%
of individuals with anterior myocardial infarction suffer from a left
ventricular thrombus (LVT) (5, 6). With the introduction of early
percutaneous coronary intervention (PCI) as a widely used treatment of
AMI, the incidence of LVT decreased dramatically. LVT is most typically
seen in patients with late-onset MI in clinical practice. It is
infrequently seen in patients who report early and receive fast
revascularization, especially in the first 24 hours after an AMI (7).

Coronavirus Disease 2019 (COVID-19) has grown significantly in scale as
a result of the development of the novel Zoonotic Severe Acute
Respiratory Syndrome Coronavirus-2. In addition to the predominance of
respiratory symptoms, cardiovascular problems have also been
reported(8).

A COVID-19 patient with ST elevation MI and LV thrombus with signs and
symptoms of pericarditis was introduced.

\textbf{Timeline:}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Timing\strut
\end{minipage} & \begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Event\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
-10 days\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
History of upper respiratory infections (URI)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Presentation\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Pleuritic chest pain, nausea, diarrhea, and cough\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
+1 day\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Pleuritic chest pain Electrocardiography: diffuse ST-segment elevation
Echocardiography: reduced ejection fraction (LVEF:45\%) Serum troponin:
within normal limits\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
+2 day\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Increased pleuritic chest pain positive Real-time RT-PCR test ECG:
Increased ST-segment elevation in precordial leads Echocardiography:
left ventricle (LV) clot and a decreased EF (35\%) Serum troponin(hsTn):
27185 (normal range: 34( Angiography: heavy thrombotic lesion on the
left anterior descending artery (LAD)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
+1 month\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Resolution of chest pain Electrocardiography: T wave inversion in
anterior and lateral leads, ST elevation in inferior leads and Q wave in
lateral leads Computed Tomography Angiography (CTA): reduction of
thrombus burden\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
+3 month\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
chest pain relieved stable vital signs Echocardiography: reduced-sized
LV clot EF=45-50\%\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Case Presentation:}

A 38-year-old man with a history of URI 10 days before admission and no
risk factor for cardiac disease was presented with pleuritic chest pain
that radiates to the scapula and shoulders, exacerbated by deep
inspiration and in supine position, nausea, diarrhea and cough starting
three days prior to admission.

Physical examinations; vital signs included blood pressure of
110/70 mmHg, pulse rate of 87 beats/min, respiratory rate of 23/min,
oximetry of 90\% on room air, and a temperature of 38.5 \selectlanguage{ngerman}°C (101\selectlanguage{english} degF).

The patient's chest pain improved on the first day of admission and
electrocardiography revealed diffuse ST-segment elevation (Figure 1).

Echocardiography showed a reduced ejection fraction (LVEF=45\%) and the
serum troponin (hsTn) was equal to 36 (normal range: 34). An initial
plan for medical treatment of acute pericarditis was in place when the
patient was admitted to the hospital.

Infectious diseases consultant added Vancomycin 2gr twice a day and
Meropenem 1gr three times a day to the treatment.

A spiral lung CT scan showed no evidence in favor of covid and
infectious diseases.

Laboratory evaluations such as viral, inflammatory, and coagulation
markers were normal. All hypercoagulability tests (activated protein C
resistance, beta-2 glycoprotein antibodies, protein S activity, and
homocysteine) were normal.

On the next day of admission, the patient's pleuritic chest pain changed
to typical pain and felt as a feeling of pressure. In addition, serum
troponin reached 27185, and SARS-CoV-2 PCR became positive.

ECG showed diffuse ST-segment elevation and increased ST elevation in
precordial leads (Figure 2).

Echocardiography indicated a large left ventricle (LV) apical clot size
(3.1cm*1.5cm) and moderate LV systolic dysfunction (LVEF 35\%).

Due to the rise of serum troponin and LV clots, an intravenous injection
of unfractionated heparin was started and the patient underwent
angiography. The results disclosed a heavy thrombotic lesion on the left
anterior descending artery (Figure 3).

On the 7\textsuperscript{th} day of admission; the patient's symptoms
disappeared gradually, Anticoagulation was switched to Rivaroxaban, and
the patient was discharged with aspirin 80 mg, clopidogrel 75mg, and
rivaroxaban 15 mg once a day.

During a one-month follow-up, electrocardiography showed T wave
inversion in anterior and lateral leads, ST elevation in inferior leads,
and Q wave in lateral leads (Figure 4). CTA revealed reduction of
thrombus burden in left anterior descending artery (Figure 5).

Based on clinical status and echocardiographic findings, continuation of
rivaroxaban 15 mg daily for three months was prescribed.

Additionally, after three months, echocardiography detected a
reduced-sized LV clot (2.2cm*0.7cm) with an increased LV systolic
function (Figure 6).

In addition, the patient had a favorable evolution and showed stable
vital signs, pain improvement, no angina, no dyspnea, and good work
ability.

\textbf{Discussion:}

The patient in this case report was recovering from COVID-19 infection
when he developed acute pericarditis symptoms, elevated cardiac injury
biomarkers, and LV clots.

Pericarditis is an inflammatory and non-ischemic condition that affects
the pericardium (1, 9). The clinical appearance varies greatly and may
be preceded by coryzal symptoms or generalized symptoms including
lethargy, diarrhea, or malaise. Symptomatic arrhythmias, heart failure,
myocardial infarction, cardiogenic shock, or sudden cardiac death may be
caused by cardiac inflammation (10). Pleuritic chest discomfort,
pericardial friction rub, and suggestive abnormalities in
electrocardiography are the clinical hallmarks of acute pericarditis
(4). The most frequent cause is infection, with viral infections being
the most frequently recognized in developed nations (11). Various
cardiovascular conditions, such as myocarditis, pericarditis, or more
generally, elevated cardiac injury biomarkers, have all been reported as
cardiac involvement in COVID-19, according to a growing body of research
(12). Acute coronary syndrome may be caused by localized inflammation at
the plaque level, which could destabilize coronary atheroma (13).

Our case demonstrated thrombotic complications such as coronary
thrombosis. LV clots can occur even in COVID-19 patients with
non-specific symptoms, and gradually progress and lead to clot formation
and coronary involvement, which shows the mysterious face of COVID-19.

This complex process indicates the necessity of screening patients for
COVID-19 disease even with non-specific cardiac symptoms (14).

Moreover, the early initiation of antiviral treatment and most
importantly, the initiation of anticoagulants after diagnosis will stop
the progressive course of the disease.

These patients are at risk of cardiac re-thrombosis and cerebral
thrombosis.Therefore, it is recommended to continue anticoagulant
treatment for at least three months (15).

\textbf{Conclusions:}

Our case demonstrated that thrombotic complications such as coronary
thrombosis and LV clots can occur even in well-appearing, COVID-19
patients with non-specific symptoms which indicates the necessity of
screening for COVID-19 disease.

Further studies are also required to analyze the role of routine
anticoagulation upon the diagnosis of COVID-19 and preventing further
threatening complications.

\textbf{List of Abbreviations:}

\begin{itemize}
\tightlist
\item
  AMI Acute Myocardial Infarction
\item
  COVID-19 Coronavirus Disease 2019
\item
  CTA Computed Tomography Angiography
\item
  ECG Electrocardiogram
\item
  hsTn High-sensitivity Troponin
\item
  LVEF Left Ventricular Ejection Fraction
\item
  LVT Left Ventricular Thrombus
\item
  RT-PCR Real Time Polymerase Chain Reaction
\item
  URI Upper Respiratory Infection
\end{itemize}

\textbf{References:}

1. Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of
Pericarditis: A Systematic Review. Jama. 2015;314(14):1498-506.

2. Little WC, Freeman GL. Pericardial disease. Circulation.
2006;113(12):1622-32.

3. Troughton RW, Asher CR, Klein AL. Pericarditis. Lancet.
2004;363(9410):717-27.

4. Salarda EM, Ocazionez-Trujillo D, Prakash SK. An unusual cause of
acute pericarditis: a case report. Eur Heart J Case Rep.
2021;5(2):ytaa535.

5. Solheim S, Seljeflot I, Lunde K, Bjornerheim R, Aakhus S, Forfang K,
et al. Frequency of left ventricular thrombus in patients with anterior
wall acute myocardial infarction treated with percutaneous coronary
intervention and dual antiplatelet therapy. Am J Cardiol.
2010;106(9):1197-200.

6. Delewi R, Nijveldt R, Hirsch A, Marcu CB, Robbers L, Hassell ME, et
al. Left ventricular thrombus formation after acute myocardial
infarction as assessed by cardiovascular magnetic resonance imaging. Eur
J Radiol. 2012;81(12):3900-4.

7. Sharma H, George S. Early Left Ventricular Thrombus Formation in a
COVID-19 Patient with ST-Elevation Myocardial Infarction. Case Rep
Cardiol. 2020;2020:8882463.

8. Panigada M, Bottino N, Tagliabue P, Grasselli G, Novembrino C,
Chantarangkul V, et al. Hypercoagulability of COVID-19 patients in
intensive care unit: A report of thromboelastography findings and other
parameters of hemostasis. J Thromb Haemost. 2020;18(7):1738-42.

9. Caforio AL, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix
SB, et al. Current state of knowledge on aetiology, diagnosis,
management, and therapy of myocarditis: a position statement of the
European Society of Cardiology Working Group on Myocardial and
Pericardial Diseases. Eur Heart J. 2013;34(33):2636-48, 48a-48d.

10. Eckart RE, Shry EA, Burke AP, McNear JA, Appel DA, Castillo-Rojas
LM, et al. Sudden death in young adults: an autopsy-based series of a
population undergoing active surveillance. J Am Coll Cardiol.
2011;58(12):1254-61.

11. Breinholt JP, Moulik M, Dreyer WJ, Denfield SW, Kim JJ, Jefferies
JL, et al. Viral epidemiologic shift in inflammatory heart disease: the
increasing involvement of parvovirus B19 in the myocardium of pediatric
cardiac transplant patients. J Heart Lung Transplant. 2010;29(7):739-46.

12. Buckley BJR, Harrison SL, Fazio-Eynullayeva E, Underhill P, Lane DA,
Lip GYH. Prevalence and clinical outcomes of myocarditis and
pericarditis in 718,365 COVID-19 patients. Eur J Clin Invest.
2021;51(11):e13679.

13. Madjid M, Safavi-Naeini P, Solomon SD, Vardeny O. Potential Effects
of Coronaviruses on the Cardiovascular System: A Review. JAMA Cardiol.
2020;5(7):831-40.

14. Bhurint Siripanthong, Recognizing COVID-19-related myocarditis Heart
Rhythm. 2020 Sep;17(9):1463-1471. Doi: 10.1016/j.hrthm.2020.05.001.

15. Chandra A, Chakraborty U, Ghosh S, et alAnticoagulation in COVID-19:
current concepts and controversiesPostgraduate Medical Journal
2022;98:395-402.

\textbf{Figure Legends}

Figure 1

Electrocardiogram presenting diffuse ST-segment elevations.

Figure 2

ECG showing diffused ST-segment elevation, and increased ST elevation in
precordial leads.

Figure 3 (a,b)

Angiogram showing non-occlusive and occlusive thrombus in the left
anterior descending artery.

Figure 4

Electrocardiogram at 1 month showing T wave inversion in anterior and
lateral leads, ST elevation in

inferior leads and Q wave in lateral leads.

Figure 5

CT-Angiogram revealed reduction of thrombus burden.

Figure 6

Echocardiogram indicating a reduced-sized LV clot (EF=45-50\%).

\textbf{Hosted file}

\verb`Percarditis Figure File TIFF.docx`  available at \url{https://authorea.com/users/651933/articles/659661-left-ventricular-thrombus-formation-in-a-covid-19-patient-with-a-complex-course-of-pericarditis-and-myocardial-infarction}

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