Thrombolysis in severe COVID-19 pneumonia with massive pulmonary embolism

Abdulrahman Alharthy, Fahad Faqihi, John Papanikolaou, Abdullah Balhamar, Mike Blaivas, Ziad A Memish, Dimitrios Karakitsos, Abdulrahman Alharthy, Fahad Faqihi, John Papanikolaou, Abdullah Balhamar, Mike Blaivas, Ziad A Memish, Dimitrios Karakitsos

Abstract

Objective: No guidelines exist for the management of massive pulmonary embolism (PE) in COVID-19. We present a COVID-19 patient with refractory acute respiratory syndrome (ARDS), and life-threatening PE who underwent successful thrombolysis.

Case presentation: A previously healthy 47 year old male was admitted to our hospital due to severe COVID-19 pneumonia [confirmed by Real-Time-Polymerase-Chain-Reaction (RT-PCR)]. He had rapidly evolving ARDS [partial arterial pressure of oxygen to fractional inspired concentration of oxygen ratio: 175], and sepsis. Laboratory results showed lymphocytopenia, and increased D-dimer levels (7.7 μg/ml; normal: 0-0.5 μg/ml). The patient was treated in the intensive care unit. On day-1, ARDS-net/prone positioning ventilation, and empiric anti-COVID treatment integrating prophylactic anticoagulation was administered. On hospital day-2, the patient developed shock with worsening oxygenation. Point-of-care-ultrasound depicted a large thrombus migrating from the right atrium to the pulmonary circulation. Intravenous alteplase (100 mg over 2 h) was administered as rescue therapy. The patient made an uneventful recovery, and was discharged to home isolation (day-20) on oral rivaroxaban.

Conclusion: Thrombolysis may have a critical therapeutic role for massive PE in COVID-19; however the risk of potential bleeding should not be underestimated. Point-of-care ultrasound has a pivotal role in the management of refractory ARDS in COVID-19.

Keywords: Acute respiratory distress syndrome; COVID-19; Massive pulmonary embolism; Point-of-care ultrasound; Thrombolysis.

Copyright © 2020 Elsevier Inc. All rights reserved.

Figures

Fig. 1
Fig. 1
Point-of-care-cardiac ultrasound (day-2) performed on our critically ill patient with COVID-19: modified four-chamber (A), and short-axis at the level of aortic valve (B) views depicting a large free-floating thrombus (white arrows) migrating to the pulmonary circulation along with severe RV dilatation/dysfunction. Also, on day-2, another short axis view (C) shows a D-shaped left ventricle in systole due to right ventricular pressure overload. On day-5 post-thrombolysis, four-chamber view (D) shows restored right ventricular function. Abbreviations: RA = right atrium, RV = right ventricle; LA = left atrium; LV = left ventricle; IVS = interventricular septum, Ao = aorta.

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Source: PubMed

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