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CASE PRESENTATION

A 78-year-old female patient with history of type 2 diabetes mellitus, hypertension, and moderate aortic stenosis (AS) on a transthoracic echocardiogram (TTE) done 1 year ago is brought to a New York City hospital with fever, fatigue, cough, and worsening dyspnea in April 2020. On arrival the patient was found to be tachypneic, hypoxic, and tachycardic. Physical examination showed an elderly female responding to verbal stimuli but in distress with increased work of breathing. Respiratory exam revealed intercostal retractions and diffusely coarse breath sounds along with crackles in both lung fields. Auscultatory findings consisted of tachycardia, with a late peaking systolic murmur that would radiate to bilateral carotid arteries. Abdomen was soft and nontender, but extremities revealed 1+ pitting edema with cold extremities. The decision was made to intubate the patient and start her on mechanical ventilation. Investigation pursued thereafter showed leukocytosis of 21,000 with predominant neutrophilia and lymphopenia. Metabolic panel revealed elevated blood, urea, nitrogen (BUN) and creatinine to 40 and 2.0, respectively, with unknown prior baseline. The CO2 was at 18, but the electrolytes were normal. A portable chest X-ray showed diffuse bilateral interstitial opacities with small bilateral pleural effusions concerning for bilateral pneumonia and congestive heart failure. Electrocardiogram (ECG) showed sinus tachycardia with voltage criteria of left ventricular hypertrophy. Patient was transferred to the intensive care unit (ICU) where she was put in airborne precautions for concerns of COVID-19 disease. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nasopharyngeal swab done earlier came back positive. While in the ICU the patient was found to be hypotensive and started on norepinephrine with escalating doses. A bedside TTE showed a hyperdynamic left ventricle (LV) with turbulent flow across the aortic valve. Further measurements revealed a mean gradient of 50 mmHg, peak velocity of 4.6 m/sec, aortic valve area of 0.90 cm2, and Doppler velocity index (DVI) of 0.20 consistent with severe AS. She rapidly deteriorated and eventually passed away within 48 hours of her initially presentation.

Epidemiology

Coronavirus-19 disease or COVID-19 refers to a viral disease syndrome caused by SARS-CoV-2. Since the onset of the first cluster of cases reported in Wuhan, China, in December 2019, the disease has spread all over the world leading to a global pandemic. There were an estimated 27,236,916 confirmed cases including 891,031 deaths globally reported by the World Health Organization (WHO) by September 8, 2020.

Valvular heart disease (VHD) consists of a host of different pathologies both acquired and congenital that lead to a myriad of hemodynamic sequelae, symptoms, and clinical presentations. The prevalence of some of these pathologies increases with increasing age. Among them, AS is the most prevalent VHD in industrialized nations that leads to a surgical or a catheter-directed intervention. However, overall, mitral regurgitation (MR) is the most common valvular disorder found in patients, especially those over the age of 75. In a study conducted in the ...

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