Intravenous Thrombolysis for Acute Ischemic Stroke during COVID-19 Pandemic in Srinagarind Hospital

Background: Stroke is the leading cause of death and disability worldwide. In COVID-19 pandemic, stroke remains to be a medical emergency. To treat patients with acute ischemic stroke [AIS], early intravenous thrombolysis is highly time sensitive. This research investigated the impact of regionally imposed social and healthcare restrictions of COVID-19 on the time metrics in the management of AIS patients admitted at the stroke unit center in Srinagarind Hospital. Objective(s): Comparison of door to needle time for intravenous thrombolysis for AIS patients before and after the COVID-19 outbreak. Material(s) and Method(s): The present study is a retrospective analysis of patients with AIS who received intravenous tissue plasminogen activator [tPA] from 1 January 2019 to 31 December 2020 in Srinagarind Hospital, Khon Kaen. The patients admitted before and after the COVID-19 outbreak [January 13, 2020, as officially announced by the World Health Organization] were screened to collect sociodemographic data, medical history information, and symptom onset status from clinical medical records and to compared door-to-needle time (DNT) for intravenous thrombolysis before and after the outbreak. Result(s): A total of 239 patients were included, of which 113 were enrolled before and 126 after the COVID-19 outbreak. According to the findings, DNT is 35.3 minutes before the pandemic and 35.8 minutes after the epidemic. Conclusion(s): COVID-19 has remarkable impacts on the management of AIS. However, DNT for before and after COVID-19 outbreak is nearly identical. It was established that administering intravenous thrombolysis to patients in the emergency room rather than the stroke unit allowed for speedier access. Therefore, a policy which provides quick AIS treatments in COVID-19 situations should be implemented.Copyright © 2023 Journal of the Medical Association of Thailand.

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.

Intravenous thrombolysis for acute ischemic stroke during two COVID-19 outbreaks in China: Wuhan pandemic and Beijing pandemic.

INTRODUCTION: The COVID-19 pandemic has had an impact on the emergency department (ED). Door-to-needle time (DNT) could be prolonged for intravenous thrombolysis (IVT) treatment. We aimed to investigate the impact of two COVID-19 pandemics on the workflow of IVT in our neurovascular ED. METHOD: We performed a retrospective analysis of patients who received IVT treatment in the neurovascular ED of Beijing Tiantan Hospital, Beijing, from January 20, 2020, to October 30, 2020, covering two COVID-19 pandemics in China. The time-based performances of IVT treatment including onset-to-arrival time, arrival-to-CT time, CT-to-needle time, door-to-needle time, and onset-to-needle time were recorded. Data on clinical characteristics and imaging information were also collected. RESULTS: Four hundred forty patients that received IVT were enrolled in this study. The number of patients admitted to our neurovascular ED began to decrease in December 2019 and was the lowest in April 2020 (n = 95). Longer DNT (Wuhan pandemic: 49.00 [35.00, 64.00] min; Beijing pandemic: 55.00 [45.50, 77.00] min) interval delays were observed during the two pandemics (p = .016). More patients admitted during the two pandemics had an 'unknown' subtype (Wuhan pandemic: 21.8%; Beijing pandemic: 31.4%. p = .008). The percentage of the cardiac embolism subtype was higher during the Wuhan pandemic (20.0%) than during other periods. The median admission NIHSS score increased during the Wuhan pandemic and the Beijing pandemic (8.00 [4.00, 12.00], 7.00 [4.50, 14.00], respectively, p < .001). CONCLUSION: The number of patients who received IVT decreased during the Wuhan pandemic. Higher admission NIHSS scores and prolonged DNT intervals were also observed during the Wuhan pandemic and the Beijing pandemic.

Multisystem Inflammatory Syndrome in Children Requiring ECMO: Anticoagulation strategies and Lessons Learned

Intro: Multisystem Inflammatory Syndrome in Children (MIS-C) is a post-infectious inflammatory response after exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which can cause acute cardiac dysfunction requiring mechanical circulatory support (MCS). MCS utilization for MIS-C is complicated by a propensity for thrombosis, which threatens circuit integrity. This study describes a cohort of MIS-C patients requiring MCS, their outcomes, and the anticoagulation strategies utilized. Method(s): A retrospective case series of patients diagnosed with MIS-C needing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) at Children's Healthcare of Atlanta from March 1, 2020 to June 30, 2022. VA-ECMO variables, laboratory data, complications, and outcomes were collected. Result(s): Seven patients (all male) with severe MIS-C required VA-ECMO for acute cardiac dysfunction. Median age was 13 years (range 4-15 years). Median ICU stay was 13 days (range 6-17 days) with a median ECMO duration of 7 days (IQR 3-8 days) and median mechanical ventilation duration of 8 days (IQR 5-11 days). All seven patients survived to hospital discharge with good neurologic outcomes. Median time to qualitatively normal ventricular function by echocardiogram was 9.5 days (IQR 3-21 days). Heparin was initially used in 6 patients, bivalrudin initially used in 1 patient, and 1 patient converted from heparin to bivalirudin for refractory systemic thrombosis. Median heparin dose was 206u/kg/d (IQR 192-276u/kg/d) with median anti-Xa levels of 0.75 (IQR 0.1-1.1) and median daily PTT 102 seconds (IQR 83-107 seconds). Median daily PTT of patients receiving bivalirudin was 86 seconds (80-93 seconds). Median R-values by thromboelastography were 38 seconds (IQR 25-55 seconds). Two patients required catheter directed thrombolysis with tissue plasminogen activator (t-PA) for refractory intracardiac thrombi, both were initially started on heparin. Significant cannula thrombosis occurred in 2 patients, 1 initially started on heparin and 1 initially on bivalrudin. Bleeding resulting in compartment syndrome occurred in one patient on heparin requiring fasciotomy of the upper extremities, this patient was not receiving t-PA. Conclusion(s): Anticoagulation management for MIS-C patients requiring ECMO is fraught with challenges. A successful management strategy may necessitate higher heparin assay levels, the use of direct thrombin inhibitors for refractory thrombosis, and the deployment of catheter directed thrombolysis. In this case series, CDT was safely and successfully used in two patients. Further studies are required to understand the optimal anticoagulation strategy for these patients to minimize complications.

Coagulopathies after vaccination against SARS-CoV-2: The sole solution might lead to another problem

The common reported adverse impacts of COVID-19 vaccination include the injection site's local reaction followed by various non-specific flu-like symptoms. Nevertheless, uncommon cases of vaccine-induced immune thrombotic thrombocytopenia (VITT) and cerebral venous sinus thrombosis (CVST) following viral vector vaccines (ChAdOx1 nCoV-19 vaccine, Ad26.COV2 vaccine) have been reported. This literature review was performed using PubMed and Google Scholar databases using appropriate keywords and their combinations: SARS-CoV-2, adenovirus, spike protein, thrombosis, thrombocytopenia, vaccine-induced immune thrombotic thrombocytopenia (VITT), NF-kappaB, adenoviral vector, platelet factor 4 (PF4), COVID-19 Vaccine, AstraZeneca COVID vaccine, ChAdOx1 nCoV-19 COVID vaccine, AZD1222 COVID vaccine, coagulopathy. The s and titles of each article were assessed by authors for screening and inclusion English reports about post-vaccine CVST and VITT in humans were also collected. Some SARS-CoV-2 vaccines based on viral vector, mRNA, or inactivated SARS-CoV-2 virus have been accepted and are being pragmatic global. Nevertheless, the recent augmented statistics of normally very infrequent types of thrombosis associated with thrombocytopenia have been stated, predominantly in the context of the adenoviral vector vaccine ChAdOx1 nCoV-19 from Astra Zeneca. The numerical prevalence of these side effects seems to associate with this particular vaccine type, i.e., adenoviral vector-based vaccines, but the meticulous molecular mechanisms are still not clear. The present review summarizes the latest data and hypotheses for molecular and cellular mechanisms into one integrated hypothesis demonstrating that coagulopathies, including thromboses, thrombocytopenia, and other associated side effects, are correlated to an interaction of the two components in the COVID-19 vaccine.Copyright © 2022, Iranian Pediatric Hematology and Oncology Society. All rights reserved.

Androgen deprivation therapy and hormonal status in men with COVID-19.

Severe course of cOVID-19 among men compared to the female led to a detailed study of the hormonal status of men with cOVID-19. The earliest works about this focused on the incidence and severity of cOVID-19 depending on the intake of androgen deprivation therapy. At the same time, different classes of androgen deprivation therapy have different effects on androgen concentration that was not always considered in the analysis. In this regard, we conducted a review of the available literature data with a targeted study of works that included androgen deprivation therapy with a unidirectional effect on the concentration of male sex hormones. In addition, we conducted a review of studies focused on the relationship between cOVID-19 and androgens (testosterone and dihydrotestosterone).Copyright © 2022 Authors. All rights reserved.

SARS-CoV-2 Therapy: Old Drugs as New Interventions

An outburst of a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has become a grave threat to global health and the economy. As of May 13, 2020, a total of 42,81,838 cases have been confirmed, with over 2,92,376 deaths worldwide. In India, 75,048 cases have been reported to date with 2,440 deaths. Management of this new coronavirus (COVID19) has mainly focused on infection prevention, case detection, monitoring, and supportive care. As there is no vaccine or specific antiviral treatment for human SARS-CoV-2, therefore identifying the drug treatment options as soon as possible is critical for the response to the COVID19 outbreak. Pro-inflammatory cascade and cytokine storm play a key role in the pathogenesis of new coronavirus. A large number of therapeutic interventions such as antiviral, antimalarial, convalescent plasma therapy, BCG vaccine, mTOR inhibi-tors, Tissue Plasminogen Activator, Human monoclonal antibodies, Anti-parasitic agents, Immunoen-hancers, Nutritional interventions, JAK-STAT signaling inhibitors, ACE2 receptor modulators, and An-giotensin II receptor blockers have been either tried or suggested for effective treatment of patients with SARS-CoV-2 disease. Hence, we recommend that all the above potential interventions must be imple-mented in terms of their safety and efficacy through proper clinical experiments to control the emerging SARS-CoV-2 disease.Copyright © 2021 Bentham Science Publishers.

Point-of-care diagnosis and monitoring of fibrinolysis resistance in the critically ill: results from a feasibility study.

BACKGROUND: Fibrinolysisis is essential for vascular blood flow maintenance and is triggered by endothelial and platelet release of tissue plasminogen activator (t-PA). In certain critical conditions, e.g. sepsis, acute respiratory failure (ARF) and trauma, the fibrinolytic response is reduced and may lead to widespread thrombosis and multi-organ failure. The mechanisms underpinning fibrinolysis resistance include reduced t-PA expression and/or release, reduced t-PA and/or plasmin effect due to elevated inhibitor levels, increased consumption and/or clearance. This study in critically ill patients with fibrinolysis resistance aimed to evaluate the ability of t-PA and plasminogen supplementation to restore fibrinolysis with assessment using point-of-care ClotPro viscoelastic testing (VET). METHODS: In prospective, observational studies, whole-blood ClotPro VET evaluation was carried out in 105 critically ill patients. In 32 of 58 patients identified as fibrinolysis-resistant (clot lysis time > 300 s on the TPA-test: tissue factor activated coagulation with t-PA accelerated fibrinolysis), consecutive experimental whole-blood VET was carried out with repeat TPA-tests spiked with additional t-PA and/or plasminogen and the effect on lysis time determined. In an interventional study in a patient with ARF and fibrinolysis resistance, the impact of a 24 h intravenous low-dose alteplase infusion on coagulation and fibrinolysis was prospectively monitored using standard ClotPro VET. RESULTS: Distinct response groups emerged in the ex vivo experimental VET, with increased fibrinolysis observed following supplementation with (i) t-PA only or (ii) plasminogen and t-PA. A baseline TPA-test lysis time of > 1000 s was associated with the latter group. In the interventional study, a gradual reduction (25%) in serial TPA-test lysis times was observed during the 24 h low-dose alteplase infusion. CONCLUSIONS: ClotPro viscoelastic testing, the associated TPA-test and the novel experimental assays may be utilised to (i) investigate the potential mechanisms of fibrinolysis resistance, (ii) guide corrective treatment and (iii) monitor in real-time the treatment effect. Such a precision medicine and personalised treatment approach to the management of fibrinolysis resistance has the potential to increase treatment benefit, while minimising adverse events in critically ill patients. TRIAL REGISTRATION: VETtiPAT-ARF, a clinical trial evaluating ClotPro-guided t-PA (alteplase) administration in fibrinolysis-resistant patients with ARF, is ongoing (ClinicalTrials.gov NCT05540834 ; retrospectively registered September 15th 2022).

Massive empyema due to Lactococcus garvieae

Introduction Lactococcus garvieae, a zoonotic pathogen, may rarely infect humans through the consumption of fish. Documented manifestations of L. garvieae infection in humans include infective endocarditis, prosthetic joint infections, liver abscesses, peritoneal dialysis-associated peritonitis, osteomyelitis, meningitis, infective spondylodiscitis, acalculous cholecystitis, and urinary tract infection. Case report An 87-year-old female was hospitalized for coffee-ground emesis secondary to acute gastritis after eating cooked fish. One week after her discharge, she developed new-onset confusion and was returned to the hospital. Chest computed tomography revealed total consolidation of the left lung and a multiloculated left pleural effusion. The patient required intubation and direct admission to the intensive care unit. Pleural fluid and blood cultures grew L. garvieae, which was susceptible to ceftriaxone, penicillin, and vancomycin. Despite intensive antibiotic therapy and supportive care for thirteen days, the patient remained in irreversibl e shock, and the family opted for comfort care. Conclusions Heretofore unreported, this case demonstrates that L. garvieae can cause bronchopneumonia and empyema. Copyright © GERMS 2022.

Electrical Impedance Tomography As a Bedside Diagnostic Tool for Pulmonary Embolism.

Electrical impedance tomography (EIT) has been shown to be of value in evaluating the distribution of ventilation. In addition, several studies, particularly case reports, have demonstrated the use of EIT in the assessment of lung perfusion. EIT may be a potential diagnostic bedside tool in the diagnosis and follow-up of acute pulmonary embolism. CASE SUMMARY: We present one case of a patient with COVID-19 who likely had pulmonary thromboembolism where perfusion scans were made before and after thrombolytic therapy. Perfusion scans showed improvement after thrombolytic therapy. This article should therefore be seen as a first step in proving the validity of EIT-derived perfusion scans as a diagnostic for pulmonary embolism. CONCLUSION: The hypertonic saline bolus EIT method as a diagnostic tool for pulmonary embolism is a promising new technique, which can be particularly meaningful for critically ill patients. Further study is required to evaluate the sensitivity and specificity of this technique and the impact on decision-making and outcomes of critically ill patients.

Recombinant tissue plasminogen activator (rTPA) management for first onset acute ischemic stroke with covid -19 and non-covid -19 patients.

OBJECTIVES: Cerebrovascular stroke (CVS) is one of the well-known complications of coronavirus-2019 (Covid-19), but less is known about the outcome and safety of thrombolytic therapy in these patients. In this study we compare the efficacy and safety of Tissue plasminogen activator (rTPA) in acute ischemic stroke (AIS) patients with or without Covid-19 infection. MATERIALS AND METHODS: A comparative prospective study in which all patients who presented with AIS and eligible for rTPA were recruited from the emergency department and classified into 2 groups (AIS with Covid-19 infection and AIS without Covid-19 as controls). Demographic data, symptoms of Covid-19, clinical examination, neuroimaging, and laboratory investigations were obtained in each patient. National Institute of Health Stroke Scale (NIHSS) and the Modified Rankin Scale (mRS) were assessed before, immediately after rTPA, and 3 months later. RESULTS: There were 22 patients in the COVID-19 group and 25 control patients. Those with COVID-19 were more likely to have a history of smoking and Diabetes Mellitus than controls. On admission, motor symptoms were more severe in patients with COVID-19. COVID-19 patients were more likely to have symptomatic intra-cerebral hemorrhage and radiological hemorrhagic transformation than controls. Onset to door time (ODT) and onset to successful reperfusion time were significantly longer in Covid-19 patients than controls. Clinical improvement and frequency of re-occlusion and recurrent ischemic stroke at 3 months follow-up did not differ between groups, although there was higher number of deaths (27.3%) in the Covid-19 group than controls (16%). CONCLUSIONS: Using rTPA is safe and effective in patients with AIS with or without COVID-19 infection despite the high frequency of hemorrhagic transformation and high number of deaths.

Cerebrovascular disease and mortality in hospitalized patients with COVID-19 in a Latin American country, Peru

Objective: This study aimed at: 1) Assessment of the frequency of stroke and related mortality rate in patients hospitalized for COVID-19 in two major hospital referral centers in Peru;2) Exploration of factors associated to mortality and dependency in these patients;3) Comparisons of frequency of admissions of stroke patients and reperfusion treatments in similar periods of time prior to (2019) and during the pandemia occurrence. Material(s) and Method(s): A retrospective cohort study was conducted in two of the largest referral hospital centers for COVID-19 in Peru. The study included patient victims of stroke and COVID-19, hospitalized between April and August 2020. Demographic, clinical and laboratory data, radiological findings, and severity levels measured by the NIHSS scale were collected. Poisson regression models to evaluate associated factors to mortality and dependency were applied. Result(s): A 31% reduction of admissions for stroke, and of 81% of intravenous reperfusion treatment, respectively, were found in 2020 when compared with 2019. 1.37% of the patients with COVID-19 experienced a stroke, with an overall mortality rate of 40.6%, and a dependency rate of 68.3% at discharge time (Rankin > 2). An age increase of 10 years was found in mortality, associated with a 29% increase in mortality risk. As well, having hypertension, chronic kidney disease, inflammatory markers (D dimer and ferritin) and the severity of the stroke were associated with mortality. Finally, the severity of stroke, lymphopenia, and inflammatory markers (D dimer and fibrinogen) were associated with greater risk of dependency. Conclusion(s): The care system of stroke patients was affected by the COVID-19 pandemic in two of Peru's major public hospitals. There was a decrease in admissions and reperfusion treatments of stroke cases, and 1.37% of patients with COVID-19 presented a stroke. Age, hypertension, chronic kidney disease, inflammatory markers and severity of stroke were associated with mortality in these patients. Copyright 2022 With Intelligence Ltd.

Recurrent upper extremity arterial thrombosis preceding a diagnosis of COVID-19.

Arterial thrombosis occurs when there is endothelial damage in the setting of hypercoagulability and arterial blood stasis. COVID-19 has been theorized to cause both endothelial damage and promote hypercoagulability by causing an imbalance of clotting factors. In many studies, there have been a large proportion of COVID-19 patients that suffered a thromboembolic event, in both the venous and arterial systems. Our patient, who did not have a significant past medical history, presented with a recurrent brachial artery occlusion despite medical and surgical management, and subsequently tested positive for COVID-19 late in his admission. In conclusion, there is high suspicion that there is a relationship between COVID-19 infection and recurrent arterial thrombosis.

Fibrinolysis Shutdown Subtype of Early Allograft Dysfunction Represents the Predominant Cohort of Patients with Graft Failure Following Liver Transplantation

Purpose: Early allograft dysfunction (EAD) is associated with an increased rate of graft failure in liver transplantation (LT), but a mechanism remains unclear. Recent experience with COVID-19 has identified that microvascular clots related to fibrinolysis shutdown [ SD (lack of ability to break down clot)] drives organ failure, which can be treated with tissue plasminogen activator (tPA). It remains unclear how SD interacts with EAD, and if it may be associated with a worse outcome in LT. We hypothesize that fibrinolysis shutdown with EAD would be an unfavorable combination with an increased risk of graft failure compared to patients with EAD without SD. Method(s): Adult liver transplant recipients underwent thrombelastography (TEG) on post-operative day-1 to assess for fibrinolysis shutdown. Fibrinolysis activity was quantified by the amount of clot strength lost from peak clot strength in 30-minutes (LY30) in the presence of tPA (75ng/ml). SD was defined as an LY30 of 0%, indicative or no fibrinolytic activity in the presence of a fibrinolytic activator (median LY30 = 8% in healthy volunteers). EAD was defined on laboratory measurements defined and validated by Olthoff et al. Graft survival analysis was conducted with logistic regression analysis when controlling for recipient severity of liver disease (MELD) and graft quality (donor risk index). Survival time was assessed with Kaplan Meier curve. Result(s): 230 liver transplant patient recipients with a median laboratory MELD of 23 were included in the analysis. Graft failure rate was 13% with a median follow up time of 345 days. EAD occurred in 31%, and SD was present in 45%. The combination of EAD and SD was associated with a 46% graft loss rate which was significantly higher than EAD without SD (8% p<0.001). When controlling for MELD, and donor risk index, EAD (OR 3.3 95%CI 1.3-8.4 p=0.014) and fibrinolysis shutdown (OR 2.9 95%CI 1.1-7.9 p=0.034) were independent predictors of graft failure. Graft survival times were significantly different when patients were stratified by EAD and SD (figure p<0.001). Conclusion(s): The combination of EAD and SD bodes poor prognosis following liver transplantation. The stark difference in survival warrants further investigation if activation of the fibrinolytic system can safely improve graft survival time in LT recipients with EAD without the risk of excessive bleeding. (Figure Presented).

RARE CASE OF MASSIVE DVT AFTER MRNA COVID-19 VACCINATION IN A PATIENT WITH CONGENITAL IVC ANOMALY

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: Deep vein thrombosis (DVT) formation is widely recognized as Virchow's Triad of hypercoagulability, venous stasis, and endothelial injury. Based on this definition, congenital aberrations of the inferior vena cava (IVC) such as atresia or coarctation classify as major risk factors to incite a DVT (1). A congenital IVC anomaly with evidence of post-COVID-19 vaccination hypercoagulability (2) suggests a risk association with thrombotic episodes. We present a case of congenital IVC interruption with development of a DVT nine days after Pfizer COVID-19 booster administration. While it is known that IVC anomalies may contribute to DVT development (1), there is scarce data identifying a COVID-19 mRNA vaccine as a direct source of massive DVT in a young adult. CASE PRESENTATION: A 28 year old male with a history of repaired coarctation of the aorta presented with severe right thigh pain that began days after the Pfizer COVID-19 booster. Four days prior, an outpatient ultrasound (US) was negative for DVT. Physical exam revealed a dusky right foot with good distal pulses. Sensation was intact throughout. The left lower extremity (LE) had no edema or tenderness. An US of the right LE showed a DVT extending from the common femoral vein to the posterior tibial vein and DVT of the greater saphenous and deep femoral vein. Left LE US showed an anterior tibial DVT. Attempted thrombolysis was made with tissue plasminogen activator therapy and thrombectomy. Given the patient's atretic IVC anatomy, some residual clot remained in the common iliac vein, and was treated with anticoagulation therapy. After two extensive surgical lyses and aggressive medical lysis, the DVT's were resolved and the patient slowly improved. Upon follow up, he is feeling much better with no further pain. Ultimately this patient will require lifelong anticoagulation and may require an IVC stent to prevent future thrombotic events. DISCUSSION: Coarctation of the aorta is a common congenital heart defect and is often coupled with additional cardiovascular anomalies (1). In our patient, imaging showed a small and near-occluded IVC, which predisposed him to vasculitic events. There is no literature describing a massive DVT in a young adult patient within days of an mRNA COVID-19 vaccine. While these thrombotic events are rare (2), this report portrays one case in which the Pfizer COVID-19 mRNA vaccine may have prompted a vascular event in a susceptible patient. CONCLUSIONS: It has been previously established that congenital IVC anomalies may contribute to increased risk of DVT (1). In this case, we observe an association of the mRNA COVID-19 vaccine with massive DVT in a young male. While this is not meant to discourage patients with congenital IVC anomalies from receiving the COVID vaccine series, it prompts the need for open discussion with healthcare providers to discuss possible adverse effects. Reference #1: Chee, Y.-L., Culligan, D.J. and Watson, H.G. Inferior vena cava malformation as a risk factor for deep venous thrombosis in the young. British Journal of Haematology. 2001;114:878-880. doi.org/10.1046/j.1365-2141.2001.03025.x Reference #2: Bilotta C, Perrone G, Adelfio V, et al. COVID-19 Vaccine-Related Thrombosis: A Systematic Review and Exploratory Analysis. Front Immunol. 2021;12:729251. doi:10.3389/fimmu.2021.729251 Reference #3: Ruggeri M, Tosetto A, Castaman G, Rodeghiero F. Congenital absence of the inferior vena cava: a rare risk factor for idiopathic deep-vein thrombosis. The Lancet. 2001;357(9254):441. doi.org/10.1016/S0140-6736(00)04010-1 DISCLOSURES: No relevant relationships by Melanie Krongold no disclosure on file for Majed Samarneh;No relevant relationships by Elena Tran No relevant relationships by Lakshmi Sheetala Vijaya

USE OF ALTEPLASE AND DORNASE FOR LYSIS OF COVID-19-RELATED LOCULATED PLEURAL EFFUSION

SESSION TITLE: Management of COVID-19-Induced Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: We discuss a case of successful use of alteplase and dornase per MIST II protocol for the management of a loculated pleural effusion secondary to COVID-19 pneumonia. CASE PRESENTATION: 52 year old male was initially admitted for MRSA bacteremia and began appropriate antibiotic therapy. His chest radiograph on presentation was unremarkable. Seven days into his hospital course he tested positive for COVID-19 pneumonia, and developed increasing shortness of breath and escalating oxygen requirements. At this time he had a large loculated left sided pleural effusion on chest computed tomography. A pigtail catheter was placed with removal of 600ml of cloudy yellowish fluid. Follow-up CXR showed slight interval improvement, however a large loculated effusion remained. Pleural fluid studies was exudative, lymphocytic predominant (78%) with elevated pleural fluid lactate dehydrogenase of 786 U/L, pH 8.0, and glucose 97mg/dl. Additional pleural fluid workup was unremarkable, including negative cultures, AFB staining, and benign cytology. After other known causes of lymphocyte predominant pleural effusion were ruled out, and following review of the current medical literature, the conclusion was made that his effusion was most likely related to COVID-19. The decision was made to attempt lysis of the loculations with alteplase and dornase per MIST II protocol. This resulted in significant chest tube output (totaling 3480ml additional output over the ensuing days) as well as marked improvement in chest imaging. The protocol was continued for 3 days which the patient tolerated well overall. DISCUSSION: COVID-19 related pleural effusions occur with an incidence of about 7.3% of cases with an overall lag time of 11 days from symptom onset. Based on observational studies, these pleural effusions are unilateral in 66.8% of cases with a lymphocyte or neutrophilic predominance and significantly elevated pleural fluid to serum LDH ratio. The differential for exudative lymphocyte predominant pleural effusions with elevated LDH include malignancy, rheumatoid effusion, tuberculosis, and viral infections. The pleural studies workup was unremarkable for these conditions. The MIST-2 protocol was followed per the original study, with instillation of tPA 10mg via pigtail catheter which was clamped for 1 hour, opened to drain for 1 hour, then repeated with dornase 5mg. To the best of our knowledge, this is the first documented case of using MIST 2 protocol for a loculated pleural effusion related to COVID-19. CONCLUSIONS: COVID-19 related loculated pleural effusion is an infrequent occurrence that present as lymphocyte predominant exudative that can loculate with elevated lactate dehydrogenase. This is the first case of using alteplase and dornase for its management and we have demonstrated that it can be both a safe and effective method. Additional prospective studies are needed to further investigate this method. Reference #1: Chong WH, Saha BK, Conuel E, Chopra A. The incidence of pleural effusion in COVID-19 pneumonia: State-of-the-art review. Heart Lung. 2021;50(4):481-490. doi:10.1016/j.hrtlng.2021.02.015 Reference #2: Ahmadinejad Z, Salahshour F, Dadras O, Rezaei H, SeyedAlinaghi S. Pleural Effusion as a Sign of Coronavirus Disease 2019 (COVID-19) Pneumonia: A Case Report. Infect Disord Drug Targets. 2021;21(3):468-472. doi: 10.2174/1871526520666200609125045. PMID: 32516107. Reference #3: Rahman, N, et al. Intrapleural Use of Tissue Plasminogen Activator and DNase in Pleural Infection. N Engl J Med 2011;365:518-526. DOI: 10.1056/NEJMoa1012740 DISCLOSURES: No relevant relationships by Zachary Chandler No relevant relationships by James Cury No relevant relationships by Peter Staiano No relevant relationships by Daniel Weigle

ACUTE MESENTERIC ISCHEMIA IN COVID-19: A DEVASTATING SEQUELAE OF A DEVASTATING DISEASE

SESSION TITLE: Extraordinary Cardiovascular Reports SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: The COVID-19 pandemic has reshaped modern history with an estimated death count over 6 million globally. Symptoms are primarily respiratory;however, COVID also confers an increased risk for hypercoagulability with the common presentations of venous and small vessel arterial thrombi (1). Acute mesenteric ischemia (AMI) is rare. We present a case of severe AMI with arterial and venous thrombi related to COVID. CASE PRESENTATION: A 50-year-old non-COVID-vaccinated male with a history of alcohol abuse presented with 1 day of emesis and abdominal pain and was found to be COVID-19 positive without respiratory symptoms. Computed tomography angiogram of the chest, abdomen and pelvis revealed normal lungs, extensive non-calcified thrombi in the abdominal aorta extending into the celiac artery causing severe stenosis, complete occlusion of the superior mesenteric, right portal, and splenic veins, partial occlusion of the extrahepatic portal vein, left lower pulmonary embolism, small bowel perfusion injury, and splenic and right hepatic lobe infarcts. He denied a personal or family history of hypercoagulability. The patient was placed on a heparin drip and underwent placement of a transjugular intrahepatic portosystemic shunt and an infusion catheter for administration of tissue plasminogen activator into the portal vein. He ultimately required a thrombectomy. Later imaging showed patency of previously occluded vessels and resolution of arterial thrombus. Over the course of his hospitalization, his respiratory status did decompensate, and he required 13 days of mechanical ventilation, after which he was extubated, transitioned to warfarin, and discharged. DISCUSSION: AMI in COVID has been identified as a rare but serious complication with a reported incidence of 3-4%, with a reported mortality of up to 47% in all-cause-related AMI(2,3). COVID causes a prothrombotic state due to its affinity to angiotensin-converting enzyme-2(ACE2) receptors on enterocytes and endothelium, allowing it to infect the cells and causing direct damage to bowel tissue and vessels. The binding of ACE2 also increases IL-6, inducing cytokine storm and hypercoagulability (1). While there are no clear guidelines, treatment mainly involves revascularization and removal of necrotic bowel. Anticoagulation generally has favorable results within 48 hours and invasive intervention is not required (1,4). Thus, early recognition of AMI as a potential complication of COVID is essential for early treatment and reduction of the staggering morbidity and mortality. CONCLUSIONS: While the incidence of AMI in COVID is low, it can have severe effects on patients and requires early recognition and treatment. Further studies are needed to develop awareness of the disease, therefore improving surveillance and standard of care to minimize the chances of these poor outcomes. Reference #1: Patel, Suyog et al. "Bowel ischemia in COVID-19: A systematic review.” International journal of clinical practice vol. 75,12 (2021): e14930. doi:10.1111/ijcp.14930 Reference #2: Kaafarani, Haytham M A et al. "Gastrointestinal Complications in Critically Ill Patients With COVID-19.” Annals of surgery vol. 272,2 (2020): e61-e62. doi:10.1097/SLA.0000000000004004 Reference #3: Cudnik, Michael T et al. "The diagnosis of acute mesenteric ischemia: A systematic review and meta-analysis.” Academic emergency medicine : official journal of the Society for Academic Emergency Medicine vol. 20,11 (2013): 1087-100. doi:10.1111/acem.12254 Chen, Can et al. "Acute Mesenteric Ischemia in Patients with COVID-19: Review of the literature.” Journal of the National Medical Association vol. 114,1 (2022): 47-55. doi:10.1016/j.jnma.2021.12.003 DISCLOSURES: No relevant relationships by Mohamed Abdelhabib No relevant relationships by Naomi Habib No relevant relationships by Daniel Rabulinski No relevant relationships by Suresh Uppalapu

A RARE CASE OF ASYMPTOMATIC COVID-19 INFECTION MASQUERADING AS PHLEGMASIA CERULEA DOLENS

SESSION TITLE: Look again: Infections and Mimics SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Phlegmasia Cerulea Dolens (PCD) is a rare and critical condition caused by venous thrombosis requiring emergent treatment to prevent limb ischemia. COVID 19 has been widely reported to cause venous thromboembolism and compromise of tissue perfusion. We report a case of PCD in a patient with asymptomatic COVID-19 infection. CASE PRESENTATION: A 60 year-old female with no known medical history, unvaccinated for COVID-19 presented with sudden onset left lower extremity pain and swelling associated with numbness. Physical examination was remarkable for left lower extremity swelling with bluish discoloration, poikilothermia, and paraesthesia. Computed tomography angiogram (CTA) chest, abdomen and pelvis revealed left lower extremity deep vein thrombosis with compromised blood flow with focal thrombosis of the IVC extending inferiorly to the great saphenous and popliteal vein, along with small bilateral segmental and subsegmental pulmonary emboli. Diffuse Ground glass opacities suspicious for COVID-19 pneumonia. COVID-19 PCR was positive. Anticoagulation with heparin drip was initiated, and the patient underwent successful left iliocaval to popliteal vein thrombectomy and venoplasty by interventional radiology with successful restoration of circulation to the affected extremity. She was eventually transitioned to apixaban. She experienced marked improvement in her symptoms post procedure. DISCUSSION: Patients with COVID 19 develop venous thromboembolisms at an alarming rate despite thromboprophylaxis. The mechanism is likely explained by the virchow's triad (venous stasis, hypercoagulable state, vessel wall injury) in the setting of increased pro-inflammatory markers. We report the first case at our institution of PCD in the setting of COVID-19.We noted that our patient had a similar presentation as those reported in literature, which include acute leg swelling associated with pain and cyanosis. Complications include venous outflow obstruction, which can result in compartment syndrome with arterial ischemia, eventually progressing to gangrene of the affected limb. PCD is a very rare but life-threatening complication caused by extensive clot burden associated with acute limb ischemia and increased mortality rates. This condition requires emergent initiation of intravenous anticoagulation and thrombectomy with or without tissue plasminogen activator (tPA). If this condition is not treated in a timely fashion, it can result in acute limb ischemia and gangrene requiring amputation. CONCLUSIONS: Physicians should recognize PCD in patients who have been exposed to COVID-19 as it is a life-threatening condition which requires emergent initiation of anticoagulation and treatment. Diagnosis is usually made with clinical examination and ultrasonography or CT imaging. Management options include open thrombectomy with leg fasciotomy or catheter directed thrombolysis or percutaneous transluminal angioplasty. Reference #1: Chun TT, Jimenez JC, Pantoja JL, Moriarty JM, Freeman S. Phlegmasia cerulea dolens associated with acute coronavirus disease 2019 pneumonia despite supratherapeutic warfarin anticoagulation. J Vasc Surg Cases Innov Tech. 2020;6(4):653-656. doi:10.1016/j.jvscit.2020.10.002 Reference #2: Gutierrez JR, Volteas P, Skripochnik E, Tassiopoulos AK, Bannazadeh M. A Case of Phlegmasia Cerulea Dolens in a Patient With COVID-19, Effectively Ttreated With Fasciotomy and Mechanical Thrombectomy. Ann Vasc Surg. 2022 Feb;79:122-126. doi: 10.1016/j.avsg.2021.07.034. Epub 2021 Oct 10. PMID: 34644637;PMCID: PMC8502248 Reference #3: : Morales MH, Leigh CL, Simon EL. COVID-19 infection with extensive thrombosis: A case of phlegmasia cerulea dolens. Am J Emerg Med. 2020;38(9):1978.e1-1978.e3. doi:10.1016/j.ajem.2020.05.022 DISCLOSURES: No relevant relationships by Arij Azhar No relevant relationships by Louis Gerolemou No relevant relationships by Wael Kalaji No relevant relationships by Steven Miller N relevant relationships by jasparit minhas No relevant relationships by houman mirtorabi No relevant relationships by Kunal Nangrani No relevant relationships by Gaurav Parhar No relevant relationships by Kiran Zaman

ENTEROCOCCUS EMPYEMA FOLLOWING EXTRACORPEAL MEMBRANE OXYGENATION (ECMO) FOR COVID-19 ARDS: A CASE REPORT

SESSION TITLE: Management of COVID-19-Induced Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Multiple pleural complications have been well described during COVID-19 infection including pneumothorax, pleural effusion and empyema. While many infections have been described as complications, here we present a case of empyema secondary to Enterococcus faecium in a patient with COVID-19 after Extra-corporeal membrane oxygenation (ECMO). CASE PRESENTATION: A 33-year-old male presented with acute respiratory distress syndrome secondary to COVID-19. He was intubated 10 days after symptom onset and subsequently placed on veno-venous ECMO, with reconfiguration to add an arterial return limb and eventually pulmonary artery return limb. During his care he was treated with remdesivir, dexamethasone and tocilizumab. His course was complicated by right heart failure requiring mechanical support, acute renal failure requiring hemodialysis, superior vena cava thrombus, multi-drug resistant Pseudomonas, Enterococcus faecalis, Klebsiella and methicillin sensitive Staphylococcus aureus infections. Eventually he was removed from ECMO on day 130. The patient remained in the ICU on positive pressure ventilation via tracheostomy. He eventually developed worsening respiratory status as well as signs concerning for an emerging infection. Broad spectrum antibiotics were initiated, and a CT chest/abdomen/pelvis was obtained that showed right pleural effusion with concern for empyema. Pleural sampling was consistent with empyema with glucose <5 mg/dL, pH <7.2, lactate dehydrogenase >200 U/L and an elevated neutrophil count. A percutaneously placed 14 french chest tube was placed and pleural irrigation with normal saline was trialed given patient need for continuous systemic anticoagulation. However, this did not sufficiently resolve the empyema and patient was started on pleural TPA/Dornase with close monitoring while on anticoagulation with clinicoradiographic improvement after a total of 6 days of therapy. Cultures eventually speciated as Enterococcus faecium and he was continued on a 6 week course of ampicillin for his empyema. DISCUSSION: Classically, Enterococcus empyema has been primarily linked with intra-abdominal infections which was not found in our patient and has not been correlated with COVID-19 infection or ECMO. Additionally, there is a significant paucity of data with regards to safety of TPA/Dornase pleural irrigation use while patients are on full dose systemic anticoagulation as was our patient. In this case he required two 3-day courses of TPA/Dornase which was tolerated well without significant complication. CONCLUSIONS: Here we describe a rare causative organism of empyema that has not been previously described in the literature as associated with COVID-19 or ECMO. Additionally, we demonstrate the safety of intra-pleural TPA/Dornase in this patient on full dose anticoagulation which is a frequent consideration when determining the method of treating empyema in complex medical patients. Reference #1: Ayad S, Gergis K, Elkattawy S, et al. Loculated empyema and SARS-COV-2 infection: A report of two cases and review of the literature. European journal of case reports in internal medicine. July 2021;8(7):002706. doi:10.12890/2021_002706. Reference #2: Bergman R, Tjan DH, Schouten MA, Haas LE, van Zanten AR. Pleural Enterococcus faecalis empyema: an unusual case. Infection. Feb 2009;37(1):56-9. doi:10.1007/s15010-007-6359-6 Reference #3: Rahman NM, Al. E, Author Affiliations From the United Kingdom Clinical Research Collaboration Oxford Respiratory Trials Unit and Oxford Pleural Diseases Unit, et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection: Nejm. New England Journal of Medicine. Nov 2011;365:518-526. doi:10.1056NEJMoa1012740. DISCLOSURES: No relevant relationships by Joshua Boster No relevant relationships by Mary Gadarowski No relevant relationships by Stephen Goertzen No relevant relationships by Amanda Hall No relevant relat onships by Erik Manninen

ACUTE STROKE MANAGEMENT DURING COVID-19 PANDEMIC

INTRODUCTION: In the coronavirus disease 2019 (COVID-19) pandemic, there may be a decrease in the number of acute stroke intervention and acute treatment, and delays in treatment periods. In this study, it was aimed to compare the clinical features of patients presenting with acute stroke during the COVID-19 pandemic and in the pre-pandemic period. METHODS: Patients hospitalized with the diagnosis of cerebrovascular disease (CVD) between January 01, 2019 and May 31, 2021 were included in the study. Demographic characteristics and stroke risk factors of the patients were recorded. Stroke type and ischemic disease subtypes were determined, and patients' admission National Institutes of Health Stroke Scale (NIHSS) score, symptom-door time, door-consultation time, door-to-door Needle time and door-groin puncture time, intravenous tissue type plasminogen activator (IV tPA) and endovascular thrombectomy (EVT) applications were recorded. Discharge modified Rankin Scale (mRS) and NIHSS scores and mortality rates were evaluated. Patients hospitalized in two separate periods of 14 months each were compared by dividing them into pre-pandemic and pandemic periods. RESULTS: Before COVID-19, 316 patients (female 45.25%, age: 66.75±13.68 years) and during the pandemic period 341 (female 41.94%, age: 68.34±13.55 years) patients were included in the study. During the pandemic period, an increase in the number of hemorrhagic CVD and transient ischemic attacks, a decrease in the number of ischemic stroke and cerebral venous thrombosis (CVT) hospitalizations, a decrease in cardioembolic strokes and an increase in lacuner ischemic CVD subtypes were observed (p<0.01). The number of large vessel atherosclerosis, IV tPA and EVT were found to be similar before and after the pandemic. In the pandemic period, although it did not reach statistical significance compared to the pre-pandemic period, prolongation was recorded in the symptom-door, door-consultation, door-needle and door-groin puncture times (p>0.05). The COVID-19 test was positive after hospitalization in 5 (1.8%) patients with ischemic stroke hospitalized during the pandemic period. During the pandemic period, admission NIHSS, discharge NIHSS and mRS scores and mortality rates were found to be significantly higher between hemorrhagic and ischemic stroke patients (p<0.01). DISCUSSION AND CONCLUSION: The COVID-19 pandemic adversely affects the management of acute stroke. The duration of acute stroke treatment is delayed due to pre-hospital and in-hospital reasons. With the heavy burden of stroke during the pandemic period, poor clinical outcome and high mortality are observed.