key: cord-0823583-5okq97do authors: Mangiameli, Andrea; Bendib, Ines; Martin, Anne-Sophie; Razazi, Keyvan; Teiger, Emmanuel; Gallet, Romain title: Feasibility of prone Position Coronary Angiography in a patient with COVID-19 pneumonia and refractory hypoxemia. date: 2020-06-13 journal: JACC Case Rep DOI: 10.1016/j.jaccas.2020.06.012 sha: e0663186817989055456889b26a0982a065664be doc_id: 823583 cord_uid: 5okq97do Abstract A 57-year-old woman hospitalized for a COVID-19 related refractory ARDS, developed, a few days later, antero-septal ST-elevation with acute systolic dysfunction. A coronary angiography was performed with the patient in prone (face-down) position, due to the necessity to maintain a reasonable oxygen-saturation during the examination. A 57-year-old woman hospitalized for a COVID-19 related refractory ARDS, developed, a few days later, antero-septal ST-elevation with acute systolic dysfunction. A coronary angiography was performed with the patient in prone (face-down) position, due to the necessity to maintain a reasonable oxygen-saturation during the examination. An otherwise healthy 57-year-old woman without previous history of cardiovascular disease was admitted into the emergency department for fever, cough and severe fatigue since 2 days. She denied chest pain, dyspnoea, and further symptoms. Physical examination revealed a blood pressure of 135/75 mm Hg, a heart rate of 104 beats per minute, an arterial oxygen saturation of 81% and a body temperature of 39.4°C. Given the Covid-19 pandemic, a RT-PCR for Coronavirus SARS-CoV-2 RNA detection was performed and was positive. The patient was hospitalized and treated with oxygen (6L/min), but within 24 hours the patient developed acute respiratory distress syndrome (ARDS) that required mechanical ventilation, Intensive Care Unit (ICU) admission and prone positioning due to a PaO2/FiO2 ratio of 57 in supine position. After a few hours, due to a sudden blood pressure drop, a 12lead electrocardiogram (ECG) was repeated and showed a ST-segment elevation in the antero-septal leads and an ST-segment depression with T-wave inversion in DIII and aVf ( Figure 1 ). She has no past medical history and was not on any medications. The differential diagnosis included acute myocardial infarction, myocarditis and Tako-Tsubo syndrome. Echocardiography showed antero-apical wall hypokinesia, with a left ventricular ejection fraction of 20% (video 1; video 2). High-sensitivity troponin T quickly increased from 119 ng/ml on the initial laboratory study to 989 ng/ml on the second sample (normal range 0 to 14 ng/ml). Given the echocardiographic changes, the regional wall motion abnormalities, and the elevated levels of myocardial necrosis markers, urgent coronary angiography was planned. However, the ARDS was so severe, that it was not possible to perform the examination with a standard approach, due to the rapid decrease of oxygen saturation, despite mechanical ventilation, in supine position (Sa02=75% under 100% FiO2). Given the need for emergency coronary angiogram and the profound hypoxemia, the patient's position was changed from supine to prone position to allow a better lung expansion, with a dramatic improvement in oxygen saturation (>95%). Therefore, we decided to perform the coronary angiography by left transradial approach in prone position with the arm along the body side and the hand in supine position ( Figure 2 ). The radial artery was accessed using a 20-gauge micropuncture needle through which a 0.025-inch guidewire was placed. A 6Fr Radifocus Introducer II sheath (Terumo, Tokyo, Japan) was inserted into the artery. A cocktail containing nitroglycerin 200 μg and verapamil 2.5 mg was then injected through the side port of the sheath after hemodilution to a total volume of 10 mL. The left main and the right coronary arteries were cannulated using the antero-posterior view with an EBU 3.5 luncher catheter (Medtronic, Mineapolis, USA), and using the right anterior oblique view with a 6 Fr Judkins right catheter ((Medtronic, Mineapolis, USA) respectively ( Figure 3) . Procedure time and X-ray time were respectively 15 and 6.2 minutes. There was no evidence of obstructive coronary disease and the final diagnosis was myocarditis although we were not able to perform MRI in this highly unstable patient. With a rapid spread worldwide, COVID-19 has become a public health emergency of international concern (1). The clinical course of SARS-CoV-2 infection is mostly characterized by respiratory tract symptoms, including fever, cough, pharyngodynia, fatigue, and complications related to pneumonia and acute respiratory distress syndrome (ARDS), often requiring mechanical ventilation (2) . Data regarding cardiovascular involvement in SARS-CoV-2 infection are sparser but it is now proven that myocardial damages or heart failure may occur (3). Coronary angiography is sometimes required in these patients but its performance may be challenged by the dramatic hypoxemia related to the ARDS. Prone position in refractory ARDS reduces the pleural pressure gradient from non-dependent to dependent regions, in part through gravitational effects and conformational shape matching of the lung to the chest cavity. As a result, lung aeration and strain distribution are more efficient. Therefore, prone positioning is a salvage therapy for some patient with severe ARDS and refractory hypoxemia (4;5). Cardiac involvement has been described in patients with Covid-19 infection and can consist in myocarditis, type 2 myocardial infarction but also type 1 myocardial infarction related to the proinflammatory and pro-thrombotic status in these patients likely to present cardiovascular risk factors (6;7). As a consequence, urgent coronary angiography is sometimes required, but may be challenging in patients with severe ARDS. Our article illustrates a case of coronary angiography through left transradial approach in a patient requiring prone position to maintain adequate levels of oxygen saturation. Coronary angiography was performed without any important technical issues. Right coronary artery was selectively cannulated in RAO view and left main was selectively cannulated in AP view. In a patient in prone position, the geometry and orientation of the heart as well as the coronary anatomy do not allow to obtain perfectly symmetric pictures of the coronary arteries using usual views. Consequently, the interpretation of coronary angiography was simply done following the heart's shape. This peculiar clinical situation is different from dextrocardia. Although we may assume that in a patient with dextrocardia, prone positioning may facilitate coronary angiography performance, it must be highlighted that cardiac orientation is not the same in patient with dextrocardia and supine positioning and in patient with levocardia and prone positioning. Thus, in dextrocardia, the most important challenges in performing coronary angiography are opposite-direction catheter rotations and mirror-like angiographic projections. Therefore, reversing right anterior oblique/left anterior oblique angles with unchanged cranial/caudal tilts (8;9), or using the double-inversion technique to normalize all angiographic pictures like in a left located heart (10) is usually enough to perform and analyse coronary angiogram in such patients. Finally, even though we did not perform percutaneous coronary intervention (PCI), performing a PCI with a patient in prone position would not be a critical issue for an experienced operator. The patients quickly developed cardiogenic shock unresponsive to vasopressor and an end-stage renal failure requiring continuous renal replacement therapy. Five days later the death was inevitable due to multi-organ failure. With the explosion of the COVID-19 pandemic and the large percentage of patients with cardiovascular risk factors presenting with refractory ARDS, prone position coronary angiography may be needed and can be performed with good safety and efficacy. -to describe the management of patients with refractory ARDS requiring coronary angiography -to describe the feasability of coronary angiography with the patient in prone position WHO | Novel Coronavirus -China. WHO. Available at Clinical features of patients infected with 2019 novel coronavirus in Wuhan Potential Effects of Coronaviruses on the Cardiovascular System: A Review Efficacy of prone position in acute respiratory distress syndrome patients: A pathophysiology-based review Prone Positioning in Severe Acute Respiratory Distress Syndrome Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19) Percutaneous transluminal coronary angioplasty in situs inversus Primary angioplasty in a patient with dextrocardia Double-inversion technique for coronary angiography viewing in dextrocardia