When a delayed cardiology consultation leads to a massive left ventricle pseudoaneurysm: collateral effects of the COVID-19 pandemic

A 64-year-old woman was admitted to a rural hospital with recurrent chest pain and inferior T wave inversion on her electrocardiogram. Despite rising troponins and a point-of-care cardiac ultrasound demonstrating a non-compressing circumferential 10 mm pericardial effusion, hospital authorities, concerned about the COVID-19 pandemic, judged the situation non-urgent and refused to transfer the patient to an urban specialized cardiovascular centre. After initiation of acute coronary syndrome optimal medical therapy, she was discharged home 2 days later. One month later, the patient developed subacute dyspnoea and recurrent pleuritic chest pain. A thoracic computed tomography angiography revealed a huge mass adjacent to the left ventricle. The patient was rapidly transferred to our institution. Transthoracic echocardiography revealed a ruptured posterolateral myocardial wall with a giant pseudoaneurysm (90 × 80 mm) communicating through a 35 mm neck (Panels A, C, and D). Fortunately, the mitral valve apparatus was spared. The massive pseudoaneurysm was also clearly seen on the left ventricular angiography (Panel B). The coronary angiogram revealed a severe culprit lesion within the right coronary artery (RCA). The patient underwent successful resection of the pseudoaneurysm, repair of the posterolateral myocardial wall with a pericardial patch (Panel E), and one coronary artery bypass graft on the RCA. She was successfully discharged 1 week after her surgery. The COVID-19 pandemic has significantly impacted all healthcare systems worldwide. Scientific societies recommend deferral of elective cardiac procedures, including coronary angiography, for stable coronary artery disease. Nonetheless, timely reperfusion by means of percutaneous coronary intervention should still be considered for unstable patients. This case clearly illustrates a disastrous collateral effect of the COVID-19 pandemic on a non-COVID patient with an acute cardiovascular condition. Panel A Initial transthoracic echocardiogram revealing the left ventricle pseudoaneurysm communicating through a large neck. Panel B The pseudoaneurysm seen on the left ventricular angiography (red arrows). Panel C Peri-operative simultaneous multiplane transoesophageal echocardiography showing both the pseudoaneurysm and the large communicating neck. Panel D Intraoperative picture showing the ruptured posterolateral myocardial wall. Panel E Post-operative transthoracic echocardiogram showing the final repair with a pericardial patch (red arrows).