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The Characteristics and Outcomes of Critically Ill Patients with COVID-19 who Received Systemic Thrombolysis for Presumed Pulmonary Embolism: An Observational Study

M. So1, D. Steiger1, M. Takahashi1, N. Egorova2, T. Kuno1.

1Mount Sinai Beth Israel Medical Center, New York, United States, 2Ichan School of Medicine at Mount Sinai, New York, United States

Abstract Number: PB0229

Meeting: ISTH 2021 Congress

Theme: COVID and Coagulation » COVID and Coagulation, Clinical

Background: Coronavirus disease 2019 (COVID-19) is associated with abnormal hemostasis, autopsy evidence of systemic microthrombosis, and a high prevalence of venous thromboembolic disease (VTE). Tissue plasminogen activator (tPA) has been used in COVID-19 patients with severe hypoxia with high clinical suspicion of pulmonary embolism (PE).

Aims: We aimed to describe the clinical outcomes of critically ill COVID-19 patients who received tPA.

Methods: A retrospective cohort study was conducted on 6,095 hospitalized COVID-19 patients in the Mount Sinai Health System at 5 hospitals in New York. 57 patients with COVID-19, who were admitted from 3/10 to 4/27, 2020 and received tPA for presumed PE were included in the analysis. Baseline demographic and clinical characteristics, indication for tPA, and overall mortality were reported.

Results: Among the 57 patients who received tPA, the mean age was 60.8 ± 10.8 years, and 71.9% (41/57) were male. PE was suspected among 75.4% (43/57) of patients with supporting findings who had rapidly worsening hypoxia or hypotension. Right ventricular (RV) strain was present in 15.8% (9/57), deep venous thrombosis (DVT) in 7.0% (4/57), increased dead space ventilation (Vd) in 31.6% (18/57) of patients. RV strain and RV thrombus were present in 3.5% (2/57), RV strain and DVT in 5.3% (3/57), RV strain and increased Vd in 8.8% (5/57), and DVT and increased Vd in 3.5% (2/57) of patients. No chest CT angiography was performed for any patients due to clinical instability from critical illness. Following tPA infusion, 49.1% (28/57) of patients demonstrated improvement in either of PaO2/FiO2 ratio, blood pressure or partial arterial carbon dioxide. Bleeding complication was seen in 1 patient. Six patients (10.5%) survived to hospital discharge. Overall mortality was 89.5% (51/57).

Table 1.
tPA indications, n (%) Total number of patients (n=57)
Sole RV strain 9 (21.1%)
RV strain and RV thrombus 2 (3.5%)
RV strain and DVT 3 (5.3%)
RV strain and increased Vd 5 (8.8%)
Sole DVT on US 4 (7.0%)
Sole increased Vd 18 (31.6%)
DVT and increased Vd 2 (3.5%)
Hypoxia and shock without clear evidence of PE 14 (24.6%)

Tissue plasminogen activator indications for patients with presumptive diagnosis of pulmonary embolism in deteriorating hypoxia and shock.

Table 2. 
Outcomes and complications, n (%) Total number of patients (n=57)
Improvement after tPA infusion 28 (49.1%)
Bleeding complications within 36 hours of tPA infusion 1 (1.8%)
Death 51 (89.5%)

Improvement with successful weaning of ventilator settings and vasopressors, outcomes and complications.

Conclusions: The overall mortality of critically ill COVID-19 patients who received tPA for presumed PE was 89.5 %. The utility of tPA for this indicaition warrants further studies.

To cite this abstract in AMA style:

So M, Steiger D, Takahashi M, Egorova N, TK. The Characteristics and Outcomes of Critically Ill Patients with COVID-19 who Received Systemic Thrombolysis for Presumed Pulmonary Embolism: An Observational Study [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 2). https://abstracts.isth.org/abstract/the-characteristics-and-outcomes-of-critically-ill-patients-with-covid-19-who-received-systemic-thrombolysis-for-presumed-pulmonary-embolism-an-observational-study/. Accessed November 29, 2023.

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