Age: 49.0
Sex: F
Vaccine: COVID19, COVID19
Symptoms: Coronary artery disease, Coronary ostial stenosis, Dyspnoea, Dyspnoea exertional, Echocardiogram
Clinical narrative: ONSET OF S/S: Approximately a week or two later I noted that when I would walk into work from our employee parking lot/garage that I would have onset of chest pressure, shortness of breath and pain radiating down both arms and occasionally my neck when it was at it's worse.  Initially, while I didn't feel like I was feeling stressed, I was concerned that I might be experiencing panic attacks.  Dismissing it as that I shared with my Husband my concerns in late February. At that point in time, we were seeing a decrease in cases and so I was hopeful that maybe my mental state and anxieties might resolve.  So I continued to dismiss the problem. Disease Progression:  Unfortunately, the symptoms continued to progress. It progressed to happening when I was leaving work or when it was required that I go anywhere in an real rush (a frequent occurrence). By early April, we went for a family vacation.  Almost every day as we walked into, around and out of the parks I would have to slow down and res to catch my breath and slow my heartrate which would spike up into the 140-160s.  By the end of the week it was happening multiple times each day. It was always initiated by an increase in activity or exertion.  We decided that it was not anxiety related and that she needed to see a doctor to pursue a diagnosis.   4/12/21: Due to already having an appointment set up with my OB/GYN prior to our vacation - that was the first appointment that I kept because I was hopeful or suspicious that my symptoms may really be menopausal in source. The hormone work-up did not reveal any abnormalities.  However, at that time they did send in a referral to  Dr., Cardiologist. 5/17/21: I met with Dr. at which an Echo and NM Stress test were ordered.   5/28/21: Echo & routine stress test were completed.  Insurance would not cover an actual NM Stress test so the order was changed to routine.  I failed the treadmill stress test within  4.42 minutes with the same symptoms I had been experiencing. Test was terminated due to worsening symptoms. , took approximately 10 minutes to recover. HR reached goal HR @ 157. At that time Dr. recommended starting a daily Aspirin tx and suggested that a possible heart cath may be needed. Dr. followed up these tests with a referral for a left heart cath, daily 81mg Aspirin and 12.5mg Metoprolol XR daily. During this almost 3 week time period my symptoms were getting increasingly worse and requiring less and less activity to instigate my symptoms.   6/15/21: Left heart catheterization procedure to evaluate the blood flow to the heart.  Impression and plan per Dr.   Impression:   Severe ostial RCA and left main disease with preserved LV systolic function.   Crescendo angina      Plan:   Findings were reviewed the patient and her family.   Ostial coronary disease raise the concern whether she had some type of aortitis but clinically there is no history for this and no prior chest irradiation.   Surgical intervention appears indicated as soon as possible and I have consulted Dr.   In the interim, continue aspirin, metoprolol. Initiate statin therapy.  (The remainder of the following record as documented by my husband and myself) They completed the procedure and it indicated two of the main blood vessels in her heart were constricted.  The vessel on the right side was 95% restricted and the vessel on the left was 65-70% restricted.  The doctors reported afterward that they had difficulty inserting the catheter.  They also indicated that they found no build-up of plaque in other vessels or other reasons for the vessels to be restricted.  They expressed surprise and confusion as to the cause of the damage to the vessels.  They walked through the risk factors and indicated that she had none of the traditional risk factors.  She never smoked.  She is not diabetic.  She is young and otherwise healthy.  They told us that they see this type of damage to the heart from people who had radiation therapy from treatment of Hodgkin?s Lymphoma when they were young.  They also indicated that this is something that can happen to Type 1 diabetics.  They expressed that this was very unusual and they did not know why she had this condition.  They felt there was a high risk of a heart attack due to the blockage and recommended that she be admitted to the hospital.  The proposed a course of treatment was traditional bypass surgery.  They felt due to the location and type of blockage that other procedures like a stent would not be feasible.   It was at this point in the consult room when the doctor shared the information above that I express my first question about whether this could be related either to a Covid infection (she was never diagnosed or had any symptoms) or due to the vaccine.  I asked this because the symptoms began after her second shot.  Because of her job we followed the news on the virus and vaccines closely.  Many reports indicated that the virus causes severe heart and lung damage.  Recently there were reports of inflammation of the heart associated with people who had recently been vaccinated.   When I proposed this connection, Dr said that the Myocarditis and Pericarditis reported to be associated with the vaccine did not present in this way.  He expressed that he did not think it was related.   Patient came out of the procedure and was admitted.  Later that evening Dr. came in to discuss the upcoming heart procedure.  He described the blockage and why it was critical that it be addressed.  He also expressed surprise that she was having this issue and did not have any of the normal symptoms of heart disease.  He described the surgery as a triple bypass to restore blood flow to the two sides of the heart affected by the blockage.  He indicated he would take a vein from her arm and a vein from her leg and bypass the affected areas of the restricted vessels.  It was not clear to me (we did not have any pictures or models to visualize the process) exactly how it would proceed but he said it is a very common procedure and of the bypass surgeries it is the easiest due to the location.  He did not expect any issues and indicated it was a 99% success rate.   In the conversation, he expressed multiple times that this was very unusual.  I asked if it was possible it could be Covid or vaccine related.  He did not believe it was related. 6/16/21 Wednesday patient spent the day being prepped for surgery.  Vein mapping, ABG, CXR completed. 6/17/21 Thursday morning, she went into surgery.  We received the updates with no indication of any issues.  After surgery Dr. came in for the post op consult.  He said that things did not go as planned.  They harvested the veins in preparation.  When they went in the ascending aorta was severely inflamed.  He said that normal thickness is a millimeter and that it is flexible.  Patient had a 6mm wall thickness and was very difficult to work with.  This caused them to only bypass 2 vessels.  He indicated he was concerned about attaching to the inflamed aorta and that it was very difficult to ensure the stitches went all the way through.  He was worried about the efficacy of the connection.  He also stated that the inflammation was unusual and that it was possible that if they had earlier diagnosed the inflammation as the cause of the restriction it might have been possible to avoid surgery and treating the inflammation would have cleared the restrictions on the vessels.  I asked again if this might be related either to Covid or to the vaccine.  This time he said that he did not know and that he would consult with others.  He also reported that he took a small part of the aorta out and had sent it to the lab for testing.  He did not indicate which tests they would do or what they were looking for specifically.    Operative Findings - per Dr. notes in MyChart:   1. The entire ascending aorta was noted to be significantly inflamed and thickened. The thickness of the aorta was noted to be approximately 5 to 6 mm in thickness. Because of the thickened aortic leaflets very hard to place an aortic cannula, antegrade catheter and placement of the proximal graft. Initially the plan was to do 2 bypasses to the left system 1 to the left anterior descending artery using the internal mammary artery and vein to the first obtuse marginal branch using a saphenous vein. Because of the inflammatory condition of the aorta it was decided to place only 1 bypass using the left internal mammary artery to the left system. This was done to avoid any unnecessary manipulation of the ascending aorta. The above-mentioned findings are consistent with aortitis.  2. The left anterior descending artery was noted with approximately 2 mm in diameter.  3. The distal right coronary artery was noted to be approximately 2.5 mm in diameter but slightly inflamed.  Patient made it to her ICU room (436) and late Thursday evening was extubated and went for a CT to see if they could see the inflammation.  That night she had to go on Bipap to help her oxygenation.   Per lab work - became very acidotic requiring Bipap post extubation that evening. 6/18/21: Friday, she continued Bipap to maintain oxygenation.  She had a heart rate issue late in the morning and had to have a pace maker attached.  Dr came back on Friday and said that he had talked to other doctors and they were going to refer patient to a Rheumatologist at OSU to evaluate if she has an autoimmune disease.   2 U RBCs for low Hgb. No s/s of active bleeding  6/19/21: Saturday went smoothly. She came off Bipap.  She was able to get up and walk out to the hall.   Chest Tubes, Cordis and foley removed. TR to SE6 stepdown unit.  Restarted on beta blocker 6/20/21: Sunday She went to the bathroom and got cleaned up.  The nurse changed the dressings on her incisions.   6/22/21: Echo completed. Ambulated in the hall.  Discharged home.