A coronary angiography was performed in the prone position in a patient with acute respiratory distress syndrome (ARDS) related to coronavirus-2019 (COVID-19), in an effort to maintain reasonable oxygen saturation. This clinical case was published in JACC Case Reports.
A woman aged 57 years with no previous history of cardiovascular disease or medication use was admitted to the hospital after 2 days of fever, cough, and severe fatigue. She did not present with chest pain, dyspnea, or other symptoms. Her admitting blood pressure was 135/75 mm Hg, she had a heart rate of 104 beats per min, an arterial oxygen saturation of 81%, a temperature of 39.4°C, and tested positive for COVID-19.
The patient was given oxygen (6 L/min) and developed ARDS within 24 hours. She was transferred to the intensive care unit, was placed in a prone position, and assisted with mechanical ventilation. An examination with a 12-lead electrocardiogram showed an elevated ST-segment in the anteroseptal leads and depression with T-wave inversion in DIII and aVf and anteroapical wall hypokinesia with a left ventricular ejection fraction of 20%. In laboratory samples, the patient’s high-sensitivity troponin T increased from 119 ng/ml to 989 ng/ml.
Given the observed symptoms, an urgent coronary angiography was needed, however the patient’s pneumonia did not allow for a standard approach. The patient was moved from a supine to a prone position, resulting in improved oxygen saturation (>95%).
The coronary angiography was subsequently performed using a left transradial approach with the arm along the body and hand in a supine position. The radial artery was accessed with a 20-gauge needle through which a guidewire (0.025 inches) was placed. Nitroglycerin (200 mg) and verapamil (2.5 mg) were injected through the side port after a hemodilution of 10 ml. The left and right coronary arteries were cannulated using the anteroposterior (EBU 3.5 launcher catheter) and right anterior oblique (6-F Judkins right catheter) views, respectively.
The procedure lasted 15 minutes, and chest radiography took 6.2 minutes to be conducted. No obstructive coronary disease was detected.
After this procedure was successfully performed, the patient developed cardiogenic shock and end-stage renal failure and died due to multiorgan failure 5 days later.
This procedure had no important technical issues. However, in this position, the anatomy of the heart did not allow for perfectly symmetric pictures to be obtained so the coronary angiography was interpreted using the heart’s anatomical shape.
“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.,” noted the report authors.
Mangiameli A, Bendib I, Martin A S, et al. Feasibility of prone position coronary angiography in a patient With COVID-19 pneumonia and refractory hypoxemia. JACC Case Reports. 2020;2(9):1302-1306.