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Research Letter
July 8, 2020

Late Coronary Stent Thrombosis in a Patient With Coronavirus Disease 2019

Author Affiliations
  • 1Hospital Universitario de La Princesa, Madrid, Spain
  • 2Instituto de Investigación Sanitaria de La Princesa, Centro de Investigación Biomédica en Red–Enfermedades Cardiovasculares, Hospital Universitario de La Princesa, Department of Cardiology, Universidad Autónoma de Madrid, Madrid, Spain
JAMA Cardiol. Published online July 8, 2020. doi:10.1001/jamacardio.2020.2459

The excessive inflammatory response and hypercoaguable state associated with coronavirus disease 2019 (COVID-19) might trigger acute coronary events or stent thrombosis. However, cases of stent thrombosis directly associated with COVID-19 have not been reported.

We describe a patient with COVID-19 developing late drug-eluting stent thrombosis. Academic ethics committee approval was waived because this was a single-case report; written informed consent was obtained from the patient.

An 81-year-old man with hypertension, coronary artery disease, and recent COVID-19 infection presented in April 2020 with an anterior ST-segment elevation myocardial infarction. Five years prior to admission, following a myocardial infarction, drug-eluting stents were implanted in his left main to left anterior descending coronary artery (LAD), circumflex coronary artery, and right coronary artery. Three months prior to admission, an exercise test with a positive result led to the implantation of a durable-polymer ridaforolimus drug-eluting stent (3 × 15 mm) in a de novo lesion in the proximal left anterior descending coronary artery, overlapping with the stent coming from the left main coronary artery. He was compliant with a dual antiplatelet regimen of aspirin and clopidogrel. Ten days prior to admission, he was admitted to another hospital for dyspnea and fever, with a final diagnosis of COVID-19 with bilateral pneumonia. A marked increase in inflammatory markers was observed, including elevated levels of D-dimer (63 μg/mL [to convert to nanomoles per liter, multiply by 5.476]), fibrinogen (850 mg/dL [to convert to grams per liter, multiply by 0.01]), lactate dehydrogenase (423 U/L [to convert microkatals per liter, multiply by 0.0167]), C-reactive protein (5.5 mg/dL [to convert to milligrams per liter, multiply by 10]), and interleukin 6 (95 pg/mL). Treatment included hydroxychloroquine, azithromycin, and oxygen, with clinical improvement. On transfer to our institution, urgent coronary angiography revealed thrombotic occlusion of the left anterior descending coronary artery stent (Figure, A). Mechanical thromboaspiration failed to retrieve any macroscopic thrombus but restored coronary flow. Optical coherence tomography revealed a large occlusive mixed thrombus (Figure, B and C) overlying a segment with uncovered struts (Figure, D). Malapposition was demonstrated at the proximal segment of the stent (Figure, E). The minimal stent area was 4.6 mm2, with a stent expansion (compared with mean reference lumen areas) of 72%. Balloon angioplasty (with a 3.0-mm, noncompliant balloon at 22 atmospheres) obtained an excellent angiographic result. Repeated optical coherence tomography revealed some residual thrombus but improved expansion and malapposition.