The pain in his chest was sudden, heavy.
Juan Sosa was at home doing pushups in the bedroom where he had isolated himself for almost two weeks after testing positive for COVID-19. His mild symptoms were long gone, and it was the final day of his quarantine.
A retired carpenter, Sosa had been vaccinated and considered himself a pretty healthy 58-year-old. He thought he had gas and wasn’t too worried. But the pain was severe so he drove himself to a walk-in clinic.
Doctors quickly determined Sosa was having a heart attack. An ambulance rushed him to HCA Florida Brandon Hospital. The last thing he remembers that day is a nurse cutting open his T-shirt.
Veteran cardiologist Hoshedar Tamboli was seeing patients at his Brandon office when he got the call about a patient in cardiac arrest.
Tamboli hurried to the emergency room. After a quick examination, he ordered Sosa moved to a cardiac catheterization lab equipped to open blocked arteries.
Sosa’s blood pressure and vital signs were dropping. Tamboli needed to figure out why, quickly.
He had performed an estimated 20,000 heart catheterizations, but the effort to save Sosa’s heart — and his life — would be a case like no other.
“Time is muscle in my business,” Tamboli said. “Like the brain, once the heart muscle dies, it doesn’t generate back.”
Sosa’s case, which played out in late September, fits a striking pattern among COVID-19 patients nationwide – one that researchers and practitioners alike are working furiously to understand.
Scientists now believe that COVID-19 patients suffer more than respiratory issues. Several studies have revealed that the virus can also damage the heart.
For those with a heart condition, the threat is even greater.
A September 2020 study found that the risk of a first heart attack increased by three to eight times in the first week after a COVID-19 infection was diagnosed. The study, published by medical journal The Lancet, followed nearly 87,000 people in Sweden infected over an eight-month period. Their risk of stroke increased up to six times.
Another study published in February in Nature Medicine looked at Department of Veterans Affairs health data for about 153,000 veterans who contracted the virus. Researchers found the veterans suffered from an elevated risk of several heart conditions for up to a year afterward.
The veterans also had a higher likelihood of experiencing irregular heart rhythms and potentially deadly blood clots, the study found. They had a 52% higher risk of stroke, a 63% higher risk of heart attack and 72% increased risk of heart failure.
The study showed that even those who weren’t hospitalized had a higher likelihood of cardiac issues. Severe COVID-19 symptoms indicated even greater risk.
Cardiologist Hoshedar Tamboli displays a picture on his computer screen from the heart angiogram taken of patient Juan Sosa at the Heart Vascular & Vein of Tampa Bay in Brandon. Studies have shown that a COVID-19 infection can increase the risk of heart attack or stroke. That may be why Sosa, 58, suffered a heart attack two weeks after he got infected. Tamboli operated on Sosa and saved his life.
How does a virus that primarily attacks the lungs also endanger the heart?
COVID-19 can spread through the bloodstream, leaving damaged cells. The same virus proteins so adept at attaching to cells in the lower respiratory system can also attach to heart tissue, said Richard Becker, a physician, professor and director of the Heart, Lung and Vascular Institute at the University of Cincinnati College of Medicine.
The body’s immune response to the invading virus, he said, can also increase inflammation and the amount of injured heart tissue.
As many as 20% of people with severe COVID-19 show signs of heart damage, Becker said.
Even mild infection can cause damage, most often from myocarditis, an inflammation of the heart that occurs two to three times in every 1,000 COVID-19 cases, Becker said. It also increases the risk of blood clots that can lead to heart attacks.
Why COVID-19 patients are more prone to clots is not clear, Becker said. It could be connected to inflammation of blood vessels and certain kinds of antibodies.
”The potential for long-term cardiovascular risk is a concern,” he said.
Sosa had all the symptoms of someone whose artery was dangerously clogged by either cholesterol plaque or a blood clot.
To find the blockage, Tamboli inserted a catheter — a hollow tube — through a small incision in Sosa’s groin and into an artery directed toward his heart. He injected dye into Sosa’s bloodstream that showed up on live X-ray images, giving the medical team a glimpse inside his arteries and heart.
Looking at the images, Tamboli discovered that Sosa’s heart had an unusual anatomy that he’d only seen in two or three other patients in his decadeslong career. Functionally, the organ was OK. But it made it difficult to identify the problem.
Tamboli knew time was pressing. Finally, he found a clot.
The cardiologist carefully fed the catheter through the blocked artery. Attached was a suction device that Tamboli planned to use to vacuum the clot.
He planned to then insert and inflate a miniature balloon to open the artery, followed by a mesh metal tube known as a stent that would keep the artery open and the blood flowing.
Then Sosa’s heart stopped.
A dozen medical staffers rushed to the lab. This was a “code blue” — Sosa needed resuscitation.
A critical care doctor directed the responders. They intubated Sosa to keep him breathing, hooking a tube to a ventilator and inserting it down his throat. They injected him with medication to increase his heart’s output. With a defibrillator, they shocked his heart.
Three medics took turns performing CPR.
In the midst of this “organized chaos,” Tamboli was still trying to open Sosa’s blocked artery. X-ray images showed his stopped heart.
“He’s dying on me, literally dying on me,” Tamboli remembered.
Under ideal conditions, steering a catheter wire through arteries toward the heart is a tricky procedure, a series of delicate, minute movements and adjustments.
Tamboli was trying to perform it on a body being jolted by defibrillators and pounded by chest compressions.
“It’s like trying to fix an engine with the engine running,” he said.
Tamboli told those performing CPR that he needed them to pause for 10-second intervals. Four times, CPR was halted.
Knowing he had little time left and only a rough idea of where the clot was, Tamboli asked a nurse for the longest stent they had. Then he fitted the 1¼-inch-long mesh tube inside Sosa’s right coronary artery.
With the stent in place, doctors were able to restart Sosa’s heart. For about a minute, he had been clinically dead.
Sosa was alive, but barely.
His blood pressure was “in the toilet” and no one in the room was confident he would survive.
“The critical care doctor tells me, ‘You know, I think he’s gone. Maybe we should go and talk to his wife,’ ” Tamboli said.
Tamboli knew it made medical sense to stop. But something inside told him to persevere. He knew Sosa was relatively young and, other than high blood pressure, had been in good health.
As a last resort, he made the decision to install a tiny heart pump inside Sosa known as the Impella. The device does much of the work of the heart, pushing out healthy blood to the organs. He hoped that it would reduce the strain on Sosa’s heart muscles, allowing them to recover.
The device was inserted through the same femoral artery. But even with the pump, Sosa’s heartbeat remained weak.
There wasn’t much more doctors could do. They took Sosa to intensive care and placed him in a medically induced coma. He was given IV drips of medication called inotropes, which makes the heart squeeze harder.
His body temperature was lowered to about 36 degrees to give his brain the best chance of surviving undamaged.
”I told his wife and the family to pray hard for divine help as we had done what we could,” the doctor said.
Sosa had not improved when Tamboli returned to the hospital the next day.
Three days later, doctors started to thaw Sosa out, slowly warming his body. Tamboli kept calling for updates.
On the fourth day, the nurse’s report gave Tamboli hope. Sosa’s medications had been reduced and he was not as reliant on a ventilator.
When Tamboli made his rounds, he examined Sosa himself. An echocardiogram showed a stronger heartbeat. Sosa occasionally opened his eyes. Standing next to their unconscious patient, doctor and nurse hugged and cried. They didn’t know Sosa but they knew how hard the medical team had worked to save him. They knew how close he had been to death.
On Sept. 28, five days after his heart attack, Sosa’s doctors removed the heart pump.
It was another two days before Sosa regained consciousness.
He woke to find his arms and legs restrained to the hospital bed, a precaution against movements that could disconnect IV drips and sensors monitoring his vital signs.
There were dark marks on his arm. His whole body felt beat up.
He thought it had been a day since the ER nurse cut open his shirt. A nurse explained he had been unconscious for a week.
He was sitting up when Tamboli entered his room. The doctor gaped.
“He was so amazed,” Sosa said. “It’s like when you see a dead person.”
Tamboli cannot say with certainty that Sosa’s COVID-19 infection caused the blood clot and his heart attack.
Normally, clots appear alongside plaque, a telltale sign of high cholesterol issues, the doctor said. To see a clot in an artery with no plaque was unusual.
Sosa had never had heart issues before. Never smoked. Never drank.
Those who’ve caught the virus seem to have higher clotting tendencies, in Tamboli’s experience. Many of his patients who are discharged after an infection end up on blood thinners, he said.
Tamboli can’t explain why Sosa survived. In his 35 years treating cardiac patients, no patient has been so close to death and lived. In cases like this he believes a higher power intervenes, be it fate or providence or God.
“That’s the law of the universe,” he said. “There’s something higher than us. There’s a bandmaster ahead.”
Sosa, who turned 59 in January, says he feels in good health but gets tired more easily.
He’s on a daily regimen of 12 pills that includes blood thinners. Every three months, he must see a heart specialist.
In the five months since his heart attack, he’s experienced many of the same emotions — relief, gratitude, an increased closeness to God and a newfound joy in life — as others who have suffered near-death experiences.
He hopes his experience will be a warning to others not to ignore symptoms that could signal heart trouble.
Sosa still exercises, but gently. He still takes on handyman jobs around the house, but no longer works through the evening.
He makes more time to be with his wife, children and three grandchildren, to walk on the beach, to enjoy life a little more.
“I know how fragile we are,” he said.