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      Acute pulmonary embolism in COVID-19 patient: a case report of free-floating right heart thrombus successfully treated with fibrinolysis

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          Abstract

          Background

          Despite the fast-growing understanding of the coronavirus disease 2019 (COVID-19), patient management remains largely empirical or based on retrospective studies. In this complex scenario, an important clinical issue appears to be represented by the high prevalence of thromboembolic events, but the data regarding high-risk pulmonary embolism (PE) is still not available.

          Case summary

          A patient with COVID-19 developed sudden shortness of breath and hypoxia. Early echocardiographic diagnosis of high-risk PE related to right heart thrombus was performed. Systemic thrombolysis was administered with excellent clinical and haemodynamic response.

          Discussion

          Pulmonary thromboembolism is a common occurrence in severe COVID-19 infection. In our experience, systemic thrombolysis proved to be effective and for this reason may be considered for life-threatening PE in COVID-19 patients.

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          Most cited references12

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          Incidence of thrombotic complications in critically ill ICU patients with COVID-19

          F.A. Klok, M.J.H.A. Kruip, N.J.M. van der Meer … (2020)
          Introduction COVID-19 may predispose to both venous and arterial thromboembolism due to excessive inflammation, hypoxia, immobilisation and diffuse intravascular coagulation. Reports on the incidence of thrombotic complications are however not available. Methods We evaluated the incidence of the composite outcome of symptomatic acute pulmonary embolism (PE), deep-vein thrombosis, ischemic stroke, myocardial infarction or systemic arterial embolism in all COVID-19 patients admitted to the ICU of 2 Dutch university hospitals and 1 Dutch teaching hospital. Results We studied 184 ICU patients with proven COVID-19 pneumonia of whom 23 died (13%), 22 were discharged alive (12%) and 139 (76%) were still on the ICU on April 5th 2020. All patients received at least standard doses thromboprophylaxis. The cumulative incidence of the composite outcome was 31% (95%CI 20-41), of which CTPA and/or ultrasonography confirmed VTE in 27% (95%CI 17-37%) and arterial thrombotic events in 3.7% (95%CI 0-8.2%). PE was the most frequent thrombotic complication (n = 25, 81%). Age (adjusted hazard ratio (aHR) 1.05/per year, 95%CI 1.004-1.01) and coagulopathy, defined as spontaneous prolongation of the prothrombin time > 3 s or activated partial thromboplastin time > 5 s (aHR 4.1, 95%CI 1.9-9.1), were independent predictors of thrombotic complications. Conclusion The 31% incidence of thrombotic complications in ICU patients with COVID-19 infections is remarkably high. Our findings reinforce the recommendation to strictly apply pharmacological thrombosis prophylaxis in all COVID-19 patients admitted to the ICU, and are strongly suggestive of increasing the prophylaxis towards high-prophylactic doses, even in the absence of randomized evidence.
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            COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up

            Behnood Bikdeli, Mahesh Madhavan, David Jiménez … (2020)
            Coronavirus disease 2019 (COVID-19), a viral respiratory illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), may predispose patients to thrombotic disease, both in the venous and arterial circulations, due to excessive inflammation, platelet activation, endothelial dysfunction, and stasis. In addition, many patients receiving antithrombotic therapy for thrombotic disease may develop COVID-19, which can have implications for choice, dosing, and laboratory monitoring of antithrombotic therapy. Moreover, during a time with much focus on COVID-19, it is critical to consider how to optimize the available technology to care for patients without COVID-19 who have thrombotic disease. Herein, we review the current understanding of the pathogenesis, epidemiology, management and outcomes of patients with COVID-19 who develop venous or arterial thrombosis, and of those with preexisting thrombotic disease who develop COVID-19, or those who need prevention or care for their thrombotic disease during the COVID-19 pandemic.
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              2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS)

              Stavros V Konstantinides, Guy Meyer, Cecilia Becattini … (2019)
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                Author and article information

                Contributors
                Rahul Mukherjee: Role: Editor
                Tan Timothy C.: Role: Handling Editor
                Mistry Nisha: Role: Editor
                Surkova Elena: Role: Editor
                Thomson Ross: Role: Editor
                Journal
                Journal ID (nlm-ta): Eur Heart J Case Rep
                Journal ID (iso-abbrev): Eur Heart J Case Rep
                Journal ID (publisher-id): ehjcr
                Title: European Heart Journal: Case Reports
                Publisher: Oxford University Press
                ISSN (Electronic): 2514-2119
                Publication date (Electronic): 28 December 2020
                Electronic Location Identifier: ytaa388
                Affiliations
                [1 ] Cardiology Unit, Medical Sciences Departement, ASST Bergamo Est, Via Paderno 21, 24068  Seriate, Italy
                [2 ] Intensive Care Unit, Medical Sciences Departement, ASST Bergamo Est, Via Paderno 21, 24068  Seriate, Italy
                [3 ] Cardiology Clinic, Sassari University Hospital , Department of Clinical and Experimental Medicine, Viale S. Pietro, 43/B, 07100 Sassari, Italy
                Author notes
                Corresponding author. Tel: +39 0792061521, Email: parodiguido@ 123456gmail.com
                Author information
                http://orcid.org/0000-0001-5136-4881
                http://orcid.org/0000-0002-9718-9107
                Article
                Publisher ID: ytaa388
                DOI: 10.1093/ehjcr/ytaa388
                PMC ID: 7799211
                SO-VID: 8978ef87-4af7-4254-b012-d35ad249a8a8
                Copyright © © The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                History
                Date revision received : 18 May 2020
                Date accepted : 17 September 2020
                Date received : 01 May 2020
                Page count
                Pages: 5
                Categories
                Subject: Case Report
                Subject: AcademicSubjects/MED00200
                Custom metadata
                article-lifecycle PAP

                Keywords: covid-19,acute pulmonary embolism,thrombolysis,case report
                Data availability:
                Keywords: covid-19, acute pulmonary embolism, thrombolysis, case report

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