Efficacy and safety of thrombolysis in COVID19 related ARDS.

INTRODUCTION: COVID19 causes significant pulmonary microthrombi in some individuals, which can lead to ARDS and death. Thrombolysis could be an effective approach in some patients with severe ARDS. We describe our experience with usage of thrombolytic agents in COVID19 critically ill patients, who were in worsening respiratory failure. METHODOLOGY: Retrospective chart analysis was done in patients who were thrombolysed between May 2020- Sept 2020. Analysis was done to find out factors associated with improvement in oxygenation and survival. RESULTS: Twenty seven patients with severe ARDS [all had respiratory rate >30, FiO2 >0.6(on NIV/HFNC) and PiO2/FiO2 ratio<120] were thrombolysed in our ICU for COVID19 causes. C.T. Pulmonary Angiography could not be done in any of the 27 patients due to poor general condition, but 2D echo was normal in most (5 had dilated RA,RV) and none of the patients was in shock. So there was no conventional indication of thrombolysis in these patients, yet after thrombolysis, we saw dramatic changes in oxygenation (defined by decrease in FiO2 by ≥0.2) in twenty patients. Five patients had major bleed. Eleven patients survived (survival rate of 40.7%) and survival rate was high { 66% (8/12)} in patients who were thrombolysed within 2 days of oxygen requirement. CONCLUSION: In this unprecedented pandemic with high mortality rates, efficacy of early thrombolysis needs to be further explored in randomised controlled trials.

Pharmacoinvasive Therapy in Treating Acute STEMI Patients in COVID-19 Era-Thrombolysis by Tenecteplase (TNK) / Streptokinase (STK) Followed by Rescue PCI of the Culprit Vessel

Background: Treating acute STEMI patients by primary PCI has dramatically fallen globally in covid era as there is chances of potential threat of spreading Covid among the non-Covid patient. Thereby, thrombolysis of acute STEMI patient either by Streptokinase (STK) or Tenecteplase (TNK) in grey zone till Covid RT PCR report to come, was the mode of treatment of acute myocardial infarction patient in our hospital. Post thrombolysis, Covid positive cases were managed conservatively in a Covid dedicated unit. Covid negative cases were treated by rescue PCI of the culprit lesion. Exact data on benefit of thrombolysis either by TNK or STK of STEMI patients in Covid era, is not well addressed in our patient population. Thereby, we have carried out this prospective observational study to see the outcomes of thrombolysis and subsequent intervention. Method(s): STEMI Patient who represented to our ER with chest pain and ECG and hs-TROP-I evidenced acute ST segment elevated myocardial infarction (STEMI), were enrolled in the study. Total 139 patients enrolled (Male:120, Female :19);average age for Male: 54yrs., female was: 56yrs. All patients were admitted in the grey zone of CCU where thrombolysis done either by TNK or STK. Positive for COVID-19, were patients excluded from intervention and managed conservatively in Covid-19 dedicated ward. Covid Negative patients were kept transferred to CCU green zone. Result(s): COVID-19 test was carried out on all studied patients. Among them, Covid-19 positive were 7.9% (11) patients and managed conservatively in dedicated Covid ward, Covid-19 negative were 92.1% (128). Primary PCI was performed in 5.03% (7). Rest was managed by Pharmacoinvasive therapy either by TNK or STK. Thrombolysis by Tenecteplase in 64% (89), Streptokinase in 17.9% (25) patient, 12.9% (18) patient did not receive any thrombolysis due to late presentation and primary PCI done in 5.4% (7). On average 2.1 days after Fibrinolysis, elective PCI carried out. Data analysis from 48 patients;chest pain duration (3.71 +/-2.8 hr., Chest pain to contact time 3.3+/-2.8hr., Chest pain to needle time 7.2 +/-12.7hr., thrombolysis to balloon time 117.5+/-314.8hr., as many of the patient develop LVF post thrombolysis. More than 50% stenosis resolution observed in 41.6% (20) patients, chest pain resolution with one hour of thrombolysis observed in 43.8% (21) patients and development of LVF in 20.8% (10) patients. Door to needle time was 30 min. At presentation of STEMI;Ant Wall MI 46.8% (65), Inferior Wall MI 52.5% (73) and high Lateral 0.7% (1). Average Serum hs Trop-I was 16656 for male and 12109 for female. LVEF were 41% for male and 48% for female. HbA1C were in Male 8.34%: Female 8.05%, SBP for Male 120mmHg: Female 128 mmHg. Total, 88 stents were deployed in 83 territories. CABG recommended for 5.03% (7) patients, PCI in 58.3% (81), remaining were kept on medical management. Stented territory was LAD 45.7% (37) and RCA 39.5% (32) and LCX 14.8% (12). Common stent used;Everolimus 61.4% (54), Sirolimus 25% (22), Progenitor cell with sirolimus 2.3%(2) and Zotarolimus 11.4% (10) Conclusion(s): In the era of COVID-19, in this prospective cohort study, on acute STEMI patient management, we found that Pharmaco therapy by Tenecteplase and Streptokinase, reduced patient symptom and ST resolution partially. Therefore, coronary angiogram and subsequent Rescue PCI by Drug Eluting Stents (DES) are key goals of complete revascularization.Copyright © 2023

Use of Tenecteplase in Acute Ischemic Stroke in the Time of SARS-CoV-2.

Tenecteplase (TNK) is a fibrinolytic drug that is administrated in a single bolus, recommended in eligible patients with acute ischemic stroke prior to mechanical thrombectomy. This study explores its usefulness in adverse situations, such as the SARS-CoV-2 pandemic. We conducted a retrospective study involving consecutive patients with suspected acute ischemic stroke treated either with intravenous fibrinolysis with alteplase during 2019 or with TNK (.25 mg/kg) between March 2020 and February 2021. A comparative analysis was made to compare patient treatment times and prognosis. A total of 117 patients treated with alteplase and 92 with TNK were included. No significant differences were observed in age, main vascular risk factors or previous treatments. The median National Institutes of Health Stroke Scale was 8 in the alteplase group and 10 in those treated with TNK (P = .13). Combined treatment with mechanical thrombectomy was performed in 47% in the alteplase group and 46.7% in the TNK group; Thrombolysis In Cerebral Infarction scale 2b-3 recanalization was achieved in 83% and 90.7%, respectively (P = .30). There was a decrease in onset-to-needle median time (165 min vs 140 min, P < .01) and no significant variations in door-needle median time. There was no significant difference in the incidence of symptomatic hemorrhagic transformation in mortality or functional independence at 3 months. The easier administration of TNK has improved the accessibility of fibrinolytic therapy, even in adverse circumstances, such as the COVID-19 pandemic. Its use appears to be safe and effective, even in patients who are not candidates for mechanical thrombectomy.

COVID-19 and Cardiac Complication: what is new?

Coronavirus disease 2019 (COVID-19) has been reported to cause cardiovascular complications such as myocardial injury, thromboembolic events, arrhythmia, and heart failure. Multiple mechanisms-some overlapping, notably the role of inflammation and IL-6-potentially underlie these complications. The reported cardiac injury may be a result of direct viral invasion of cardiomyocytes with consequent unopposed effects of angiotensin II, increased metabolic demand, immune activation, or microvascular dysfunction. Thromboembolic events have been widely reported in both the venous and arterial systems that have attracted intense interest in the underlying mechanisms. These could potentially be due to endothelial dysfunction secondary to direct viral invasion or inflammation. Additionally, thromboembolic events may also be a consequence of an attempt by the immune system to contain the infection through immunothrombosis and neutrophil extracellular traps. Cardiac arrhythmias have also been reported with a wide range of implicated contributory factors, ranging from direct viral myocardial injury, as well as other factors, including at-risk individuals with underlying inherited arrhythmia syndromes. Heart failure may also occur as a progression from cardiac injury, precipitation secondary to the initiation or withdrawal of certain drugs, or the accumulation of des-Arg9-bradykinin (DABK) with excessive induction of pro-inflammatory G protein coupled receptor B1 (BK1). The presenting cardiovascular symptoms include chest pain, dyspnoea, and palpitations. There is currently intense interest in vaccine-induced thrombosis and in the treatment of Long COVID since many patients who have survived COVID-19 describe persisting health problems. This review will summarise the proposed physiological mechanisms of COVID-19-associated cardiovascular complications. Copyright © 2022, Anka Publishers. All rights reserved.

THROMBUS IN TRANSIT CAPTURED BY BEDSIDE ULTRASOUND: A LIFE-SAVING TOOL

SESSION TITLE: Thrombosis Jamboree: Rare and Unique Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Point of care ultrasound used by the provider is rapidly expanding in internal medicine. Thrombus in transit (TIT) is defined on ultrasound as mobile echogenic material temporarily present in the right heart chambers to the pulmonary circulation via the tricuspid valve or systemic circulation via an atrial septal defect. In this case, we were able to identify echogenic material traversing the tricuspid valve into the pulmonary circulation, which confirmed the diagnosis of pulmonary embolus [1] CASE PRESENTATION: This is a 71-year-old female with a history of hypertension who presented to the emergency room with 4-day pleuritic chest pain, productive cough, fever, and exertional dyspnea. She was hemodynamically stable, afebrile, tachycardic, and tachypneic. Initial diagnostic workup demonstrated elevated cardiac enzymes and creatinine, ground-glass opacities on chest CT, positive COVID PCR, and sinus tachycardia with nonspecific T wave abnormalities. Given her renal insufficiency, CTA was initially held off. The patient was found to have right lower extremity deep venous thrombosis, and a heparin infusion was started while waiting for a V/Q scan. Shortly after admission, she had a syncopal episode after using the bathroom. CPR was initiated for suspected cardiac arrest, and a bedside ultrasound demonstrated a sizeable mobile thrombus in the right atrium traversing the tricuspid valve into the right ventricle. Given this finding, we elected to move forward with CTA chest, and this study confirmed extensive bilateral PE with right heart strain. DISCUSSION: TIT is a rare emergency in PE (4%) with a staggering mortality rate twice as high as PE without TIT [2]. The gold standard for diagnosis of PE is CT angiogram, and early echocardiography is a cornerstone in diagnosis and risk stratification. However, patients similar to the one discussed in this care may present with conditions preventing timely utilization of these tools. POCUS allows for the rapid assessment and implementation of time-sensitive treatments. Historically, it has been a must-have skill set among ER and critical care physicians. Only 35% of internal medicine residency programs have fully integrated formal diagnostic POCUS within the past decade despite increasing interest among trainees. The expeditious medical decision made for our patient was possible following a focused echocardiogram performed by an internal medicine resident. In patients with massive PE, only 35% of echocardiograms obtained within 24 hours were done in the ER, and still, 1 in 6 happened after 6 hours [3]. CONCLUSIONS: As with any operator-dependent skill, proficiency in POCUS is a prerequisite for reliable findings and time-sensitive medical decision-making. POCUS only becomes a lifesaving tool in experienced hands. Hence, it is imperative that internal medicine residency programs consider this tool an essential component of resident training. Reference #1: Arboine-Aguirre L, Figueroa-Calderón E, Ramírez-Rivera A, et al. Thrombus in transit and submassive pulmonary thromboembolism successfully treated with tenecteplase. Gac Med Mex. 2017;153(1):129–33. Reference #2: Casazza F, Bongarzoni A, Centonze F, Morpurgo M. Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism. Am J Cardiol. 1997;79(10):1433-1435. doi:10.1016/s0002-9149(97)00162-8 Reference #3: Torbicki A, Galié N, Covezzoli A, et al. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol. 2003;41(12):2245-2251. doi:10.1016/s0735-1097(03)00479-0 DISCLOSURES: No relevant relationships by Varinder Bansro No relevant relationships by Olayiwola Bolaji No relevant relationships by clarence findley No relevant relationships by Faizal Ouedraogo

TCTAP C-105 Nightmare in Cathlab- When Simple Case Turns to Complex by Tearing Off the Stent Delivery System Shaft

Clinical Information Patient Initials or Identifier Number: Mr. AL Relevant Clinical History and Physical Exam: 59-year-old gentleman. CAD risk factors: Hypertension, Diabetes Mellitus, Dyslipidaemia, Positive family history of CAD. Admitted with Acute Anterior MI & got Tenecteplase. Relevant Test Results Prior to Catheterization: Troponin-I: >50000 ng/L, ECG: ST Elevation in V1-V6, Echo: Anterior wall is hypokinetic with Mild LV systolic dysfunction (EF- 45%). Hb-14.2 gm/dl, Creatinine: 1.12 mg/dl, Na- 135, K- 4.0, Cl- 100 m mol/L, Plasma BNP: 235 pg/ml, COVID-19 RT-PCR- Negative, S. Bilirubin- 0.3 mg/dl, ALT- 45 IU/L, AST- 107 IU/L, Anti-HCV- Negative, Anti-HIV- Negative, HbsAg- Negative, Relevant Catheterization Findings: LMCA: Normal. LAD: Got 90-99% narrowing in its proximal segment followed by 90-99% diffuse disease. DG1 is small and diseased. DG2 has got sub-total occlusion at its origin. LCX: Good size artery with mild ostial narrowing & 50% narrowing in its mid segment. Principal OM has got 50% narrowing in its ostium. RCA: Dominant artery has got 60% narrowing in its proximal segment. PDA is a good size artery & got mild irregular narrowing in its proximal segment. Recommendation: PCI to LAD [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: LCA was engaged with guiding catheter EBU -3.5 (6F). Sion Blue wire crossed the lesion of LAD, another wire crossed the lesion of Diagonal branch and pre-dilatation was done with 2.0 x 15 mm balloon at 08-10 ATM. Proximal lesion was stented with a 2.75 mm x 18 mm stent (Xience Alpine) at 12-14 ATM. After withdrawing the wire following angiogram showed proximal LAD was well dilated but mid LAD having a long dissection which interrupted the distal flow. So, decided to put stent in mid LAD. Again, repeated ballooning was done in mid LAD to prepare the lesion and a 2.25 mm x 28 mm stent (Xience Xpedition) was taken for mid LAD but stent didn't cross the mid LAD lesion. During stent withdrawal, it was struck in the previous Proximal stent and proximal calcified segment. When trying to pull it back, the delivery system shaft was tear off. Tried to get the shaft by coronary snare but failed to get it back. Finally, he was recommended to retrieve the torn delivery system & stent surgically. [Formula presented] [Formula presented] [Formula presented] Conclusions: • Stent with torn delivery system entrapment might not be rare. • In this situation, emergency decision to tackle the situation and Bail out decision to send the patient for surgical retrieval of the delivery system & stent saved the life of the patient. Take Home Message: • No case is simple in intervention. • Preparedness to tackle any untoward consequence is the key to success and save lives.

Impact of COVID-19 pandemic on STEMI thrombolysis and Emergency Department's performance in a non-PCI capable tertiary hospital.

INTRODUCTION: Some guidelines had recommended "thrombolysis first" in ST-elevated myocardial infarction (STEMI) during the Coronavirus Disease 2019 (COVID-19) outbreak. The impact of COVID-19 solely on STEMI thrombolysis is lacking as most studies reported outcomes related to percutaneous coronary intervention (PCI) setting. Thus, this study aimed to assess the impact of the COVID-19 pandemic on STEMI thrombolysis outcomes and the Emergency Department's performance in a non-PCI capable centre. METHODS: This single-centre retrospective study analysed data on consecutive STEMI patients who received thrombolytic therapy from May 2019 to December 2020 (20 months) in a non-PCI capable tertiary hospital. Total population sampling was used in this study. We compared all patients' characteristics and outcomes ten months before and during the pandemic. Regression models were used to assess the impact of COVID-19 pandemic on door-to-needle time (DNT), mortality, bleeding events, and the number of overnight stays. RESULTS AND DISCUSSION: We analysed 323 patients with a mean age of 52.9 ± 12.9 years and were predominantly male (n = 280, 88.9%). There was a 12.5% reduction in thrombolysis performed during the pandemic. No significant difference in timing from symptoms onset to thrombolysis and DNT was observed. In-hospital mortality was significantly higher during the pandemic (OR 2.02, 95% CI 1.02-4.00, p = 0.044). Bleeding events post thrombolysis remained stable and there was no significant difference in the number of overnight stays during the pandemic. CONCLUSION: STEMI thrombolysis cases were reduced during the COVID-19 pandemic, with an inverse increase in mortality despite the preserved Emergency Department performance in timely thrombolysis.

STROKE THROMBOLYSIS DURING THE COVID PANDEMIC IN INDIA - A TALE OF TWO WAVES & LESSONS LEARNT

Background: The world was witness to a pandemic never experienced by this generation. The call to arms was answered by each branch of medicine, each fighting separate wars. The war, we as neurologists faced was the “Battle for the Vessels”. Health care workers are a precious resource in Low-Middle-Income-Countries. Hence, exposure to a covidpositive patient for a “full hour” during thrombolysis, isn't warranted. Hence Tenecteplase use which fits the bill “ideally” and “literally” was analysed in this study against Alteplase in strokes with covid-positivity. We analyse the factors which affect their action and the role covid had, in each scenario. Methods: This is an ambi-spective observational study of 37 patients in an apex tertiary-care centre in India. Routine stroke variables were assessed including follow-up imaging, functional outcomes at 3 months. The results were also analysed with the thrombolysis data from covidnegative individuals too in the same period. Results: Among the covid-positive patients 62.16% patients received tenecteplase while 37.83% received alteplase. Although the baseline characteristics were similar, the time-metrics for thrombolysis were significantly favourable in the tenecteplase arm. The median-hospital stay was shorter in the tenecteplase group as was the in-hospital mortality. On follow-up at 3 months, the median mRS-score was significantly favourable in the tenecteplase group. Conclusions: Thrombolysis during the pandemic has been a challenge in many ways especially in resource limited settings. This study shows that there needs to be a conscious and judicial transition towards tenecteplase during the pandemic, where healthcare workers are a precious resource too.

Pediatric Cerebral Infarction associated with recent SARS-CoV-2 mild infection treated with intravenous thrombolysis and endovascular thrombectomy

Objective: N/A Background: Acute ischemic stroke is a major cause of disability worldwide in adults and children. It is a common disease after middle age but uncommon in the pediatric population. Disabling arterial ischemic strokes due to acute intracranial large vessel occlusion within 3-4 weeks of SARS-CoV-2 (COVID-19) infection have been described. Design/Methods: N/A Results: A 15-year-old boy presented with sudden onset right-sided weakness and expressive aphasia witnessed by mother. He presented within 50 minutes of symptom onset to the regional ER facility. Around 4 weeks ago, patient had mild SARS-Cov-2 infection with flu-like symptoms and mild chest pain that worsened with exertion lasting 3-4 days. Neurological examination revealed diminished fluency, anomia, and right upper extremity drift. Initial non contrast computed tomography (CT) demonstrated hyperdense left middle cerebral artery (MCA) sign with subtle loss of gray/white matter differentiation in the left anterior insula. Aphasia and right-sided weakness worsened as he was coming back from CT 2 hours after symptom onset. Intravenous Tenecteplase was administered. CT angiography of head/neck confirmed left proximal M2 occlusion with no arterial dissection. Patient underwent successful mechanical thrombectomy. Three days later his deficits completely resolved. Transthoracic echocardiography with contrast bubble study was unremarkable. Laboratory workup demonstrated mildly low ATIII, positive Factor V Leiden screen with negative genetic testing, positive SARS coronavirus-2 IgG, mildly low PTT. Remaining coagulopathy workup was unremarkable. Conclusions: To our knowledge this is the first case of large vessel occlusion in a pediatric patient treated successfully with both intravenous thrombolysis and mechanical thrombectomy associated with recent SARS-Cov-2 infection. The AIS etiology in our case remains uncertain as abnormal laboratory findings do not explain this presentation. There is high clinical suspicion of an embolic event as possible explanation, possibly related to SARS-CoV-2 postinfectious stage.

Tenecteplase use in the management of acute ischemic stroke: Literature review and clinical considerations.

PURPOSE: Several research articles have been published within the last decade comparing the use of tenecteplase to alteplase in ischemic stroke management. Prior reporting on the comparative therapeutic efficacy and safety profiles of tenecteplase and alteplase is reviewed. SUMMARY: Tenecteplase is a variant of native tissue-type plasminogen activator, which rapidly promotes thrombolysis by catalyzing formation of the serine protease plasmin. Tenecteplase has theoretical advantages over alteplase as it has greater fibrin specificity and has a longer half-life than alteplase. This allows the administration of a single bolus over 5 to 10 seconds, as opposed to a bolus followed by a 1-hour infusion with alteplase. While currently approved by the Food and Drug Administration for the treatment of ST-segment elevation myocardial infarction, tenecteplase has also been studied in the treatment of acute ischemic stroke and has extensive data for this off-label indication. The most comprehensive trials to date evaluating the use of tenecteplase in acute ischemic stroke include the TNK-S2B, Australian TNK, ATTEST, Nor-Test, and EXTEND-IA TNK trials. Findings from these randomized controlled studies suggest that tenecteplase is at least as efficacious as alteplase in terms of neurological outcomes. The majority of these studies also reported a trend toward improved safety profiles with the use of tenecteplase. CONCLUSION: Current clinical evidence shows that tenecteplase is not inferior to alteplase for the treatment of ischemic stroke and suggests that tenecteplase may have a superior safety profile. Furthermore, tenecteplase also has practical advantages in terms of its administration. This can potentially lead to a decrease in medication errors and improvement in door to thrombolytic time.