A case series published in the European Heart Journal – Cardiovascular Pharmacotherapy highlights four patients needing mechanical ventilation for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, who were diagnosed with high-risk pulmonary embolism (PE), and underwent systemic fibrinolysis with full-dose alteplase, with three of them achieving rapid hemodynamic and respiratory success.
Roberta Della Bona, MD, CardioThoracoVascular Department, Ospedale Policlinico San Martino – IRCCS, Genoa, Italy, and colleagues, retrospectively reviewed clinical charts of all intubated patients who were admitted to the dedicated COVID-19 ICU wards of their hospital from March 1 to April 20, 2020. Of the 90 SARS-CoV-2-infected patients admitted for acute respiratory distress syndrome (ARDS) related to COVID-19, eight patients were diagnosed with PE during their ICU stay, and four were thrombolysed according to physicians’ discretion.
The patients developed sudden hemodynamic instability and PE diagnosis was made with bedside echocardiography, revealing either direct (“thrombus-in-transit”, 2 patients) or indirect (right ventricular strain) signs of PE in all patients. Three cases had been treated with anticoagulants before PE, with one case suffering PE while on sodium heparin, one while on a full weight-adjusted dose of enoxaparin, and the third case two days after sodium heparin full anticoagulation was downgraded to a prophylactic dose of enoxaparin.
Computed tomography pulmonary angiography (CTPA) was performed on three patients, revealing segmental and subsegmental embolic material in all instances, and a “saddle embolus” in one case. All four patients were administered alteplase 100 mg over two hours, followed by anticoagulation with sodium heparin. None of the four cases experienced bleedings, and three patients survived to discharge from ICU.
“Only another small case series reported the use of thrombolytics in COVID-19 patients with PE, whereas fibrinolysis was not mentioned in other cohort studies,” the authors noted, suggesting “this is probably due to bleeding concerns due to the unfamiliar coagulopathy often associated with thrombocytopenia, occurring in up to 58% of subjects with severe disease, and the difficulty to disentangle the hemodynamic impact of PE from those of ARDS and pneumonia.”
The authors believe that in COVID-19 patients, ARDS and venous thromboembolism/PE are “strictly interrelated.” They added “it is likely that the prevalence of imaging-evident PE is higher than reported and dependent on the logistics and willingness to move highly infectious patients to an imaging suite. Evidence of ‘thrombus in transit,’ but perhaps also indirect signs of right heart strain, might then prompt systemic fibrinolysis even if CTPA confirmation is not available or feasible.”