key: cord-0988982-nivf291p authors: Jalalian, Rozita; Sadraee, Javad; Azizi, Soheil; Bagheri, Babak; Iranian, Mohammadreza title: Pulmonary valve sarcoma in patient with coronavirus disease of 2019 (COVID‐19), mimicking pulmonary thromboembolism, a very rare case date: 2021-09-29 journal: Echocardiography DOI: 10.1111/echo.15213 sha: 4f95a078025f9e151aa1c390578041f48f88eea4 doc_id: 988982 cord_uid: nivf291p Pulmonary artery and pulmonary valve sarcoma are malignant and very rare vascular tumors with aggressive clinical course and very poor outcomes. Patients affected by coronavirus disease of 2019 (COVID‐19) are at a higher risk for thromboembolism complication. We describe a young woman with a history of coronavirus pneumonia and progressive dyspnea, hemodynamic disturbance, edema with initial evaluation, and clinical diagnosis of pulmonary thromboembolism. But further imaging study and pathology demonstrated giant sarcoma of pulmonary valve, obstructing pulmonary valve and extending to right ventricular outflow tract and main of pulmonary artery. Pulmonary artery sarcomas (PASs) are the most common primary tumors of the pulmonary artery (PA). PASs are malignant and rare tumor and predominantly presented among patients from their third to seventh decade. Women are involved twice as often as men. The most common clinical manifestation of PASs is dyspnea followed by chest pain, cough, and hemoptysis. Systematic symptoms of PASs are less rare and they include weight loss, syncope, and fever. The presence of these symptoms often causes misdiagnosis of pulmonary thromboembolism (PTE). 1-3 A 40-year-old woman presented at the emergency department because of progressive dyspnea, orthopnea, edema, weakness. She has involved with COVID-19 about 2 months ago according to polymerase chain reaction (PCR) and chest computed tomography (CT). At the same time, she suffered from fever, cough, and dyspnea and she was admitted to another hospital for 10 days due to hypoxemia. She was treated with corticosteroids and supportive therapies and discharged after improving her general condition, but she did not completely recover from respiratory symptoms in spite of adequate treat- F I G U R E 2 Chest X-ray. Chest X-ray showed significant cardiomegaly, RV enlargement, and prominent main of PA and left PA without evidence of pulmonary venous congestion severe RV pressure overload and signs of severely increased RV afterload pattern. In PSAX view, very large size nonhomogeneous solid mobile mass is seen in distal right ventricular outflow tract (RVOT) extended to main PA and has attachment to pulmonary valve (PV). The PV obstruction was severe and blood flow to main PA was reduced. Left and right PA and pulmonary bifurcation were evaluated, which were spared without any mass. Color doppler study of tricuspid valve (TV) inflow showed severe tricuspid regurgitation (TR) and hemodynamic study with continuous doppler wave in apical four-chamber view demonstrated TR peak velocity of 4.4 m/sec (TR peak gradient: 77 mm Hg). IVC was severely enlarged (2/75 cm diameter) without respiratory collapse. Therefore, hemodynamic study estimated RA pressure about 20 mm Hg, more compatible with chronic course of disease and indicating of more gradual increasing of RV pressure rather than acute event. Massive pericardial effusion was seen more localized in posterolateral of left ventricle (LV) (maximum diameter: more than 3 cm). There was significant respiratory variation in Doppler study of mitral valve (MV) and TV diastolic inflow velocity more than 30% ( Figure 4 ). In laboratory data, d-dimer was increased about 4000 µg/L and probrain natriuretic peptide (pro-BNP) 12 500 ng/day. According to previous history of the COVID-19, ECG manifestation, echocardiography, chest X-ray, spiral chest CT, laboratory data and abnormal hemodynamic condition, massive sub-acute PTE was highly suggested. Due to our patient hemodynamic disturbance, massive pericardial effusion and giant mass, emergent cardiac consultation with cardiovascular surgical team for surgical resection was done, and the patient was taken to operating room. Patient had stable hemodynamic in ICU, intubated easily, and discharged after 7 days without any cardiac event. TTE was performed before discharge of the patient. RV and RA were severely enlarged. RV systolic function was severely impaired and severe TR and severe PI was seen. No residual mass was seen in RVOT, PV, PA, and main of PA. Continuous doppler wave study showed peak TR velocity 4 m/sec and short pressure half time (PHT:24 msec) and in 2D study evidence of increased RV after load pattern was permanent. IVC plethora and engorgement without respiratory collapse was seen ( Figure 6 ). Pulmonary CT angiography was done before discharge that any mass or thrombus in pulmonary vasculature was not seen. In addition, abdominopelvic and brain CT for further evaluation were performed, which were not abnormal. These two conditions are likely to be a disease spectrum. Tumor emboli are frequently reported in autopsy specimens, and may even be asymptomatic. When PH does develop, progressive and fatal right ventricular failure ensues. 12 Patients with COVID-19 pneumonia and high D dimer value has higher prevalence PTE and myocarditis. [13] [14] [15] [16] Prior infection with COVID-19 pneumonia in our case maybe the other causes of RV failure and also masquerading sarcoma. On the other hand, RV dysfunction due to cardiotoxicity of chemotherapy may considered as the other mechanism for progression of RV failure in our patient. Chemotherapy could induce impairment of RV structure, function, and mechanistic. 17, 18 Our case report emphasizes that PASs should always be included in the differential diagnosis of PTE especially if symptoms progress despite anticoagulation therapy (or any risk factor for deep vein thrombosis is not present). However, our patient underwent surgery immediately due to impaired hemodynamic and was diagnosed early compared to the time of hospitalization. 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