Intravenous thrombolytic treatment of a patient who had a stroke after COVID-19

The infection, reported by the WHO as COVID-19, may occur with asymptomatic or mild symptoms, resulting in shock and even death. Stroke occupies an important place among the neurological complications of this disease. In the acute period, intravenous (IV) alteplase therapy is useful in patients suitable for the treatment. This case report includes a 70-year-old patient with mild COVID findings, who had an early complication of stroke and who received a nearly complete benefit from thrombolytic therapy. Stroke can occur in COVID patients at an early stage of the disease. IV thrombolytic therapy should be administered in appropriate patients during the period of acute stroke. As far as we know, the earliest application in our country was carried out in our hospital and was quite successful. After the treatment, the symptoms of COVID-19 also regressed and he was discharged on the 5th day of his hospitalization.Copyright © 2021, Derman Medical Publishing. All rights reserved.

Successful Treatment of Subclavian Artery Thrombosis by Catheter-Based Thrombus Aspiration and Thrombolytic Therapy: A Case Report

Clinical Information Patient Initials or Identifier Number: BP4****/22 Relevant Clinical History and Physical Exam: A 55 Y / Female C/C : Pain, numbness, cold sensation & weakness of left upper limb for 2 hours. Risk Factor : Hypertension, diabetes mellitus O/E : Pale, cold and absent of radial, ulnar, brachial pulse of left upper limb. Muscle power 3/5 left side. So2 86%, BP undetectable. Right upper limb were normal. BP 160/90 mm of hg, pules : 112 b/min, RR : 26/min. Body Temperature 37.5 C [Formula presented] [Formula presented] Relevant Test Results Prior to Catheterization: CBC : WBC 7450, HB % 10.8 g/dl, ESR 20mm in 1st hour, Platelets : 262000, SARS Cov2 Antigen : Negative PT 14.3 sec, INR : 1.07 APTT : 32.4 sec. blood group: O positive Serum Creatinine : 1.1 mg/dl Plasma glucose 9.7 mmmol/l HIV Ab : Negative HBs Ag : Negative Anti-HCV : Negative Urine R/E : Normal lipid profile : Cholesterol 280mg/dl Vascular duplex ultrasound of left upper limb : A dilated echogenic thrombus had blocked the left subclaviav artery lumen. Relevant Catheterization Findings: Conventional angiography with the lowest amount of contrast agent through the right femoral artery, revealed that left subclavian artery thrombosis with total occlusion distal to Left internal mammary artery. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: A5Fr MPA catheter with side holes was negotiated through a right femoral sheath and was placed in the left subclavian artery. Initially thrombus aspiration was done with Eliminate aspiration catheter (TERUMO) with no success. Then suction was done with the MPA catheter itself with partial removal of thrombus. Then a 5Fr Pigtail catheter was placed inside the thrombus and kept in situ. For residual thrombus 250,000u of Inj. Streptokinase as a thrombolytic drug was given through the Pigtail catheter as bolus over 30 min. The maintenance dose 100,000 u per hour was given over 24 hours through the Pigtail catheter via infusion pump. After 24 hours of thrombolytic therapy, her pain was reduced, the left hand became slightly warm, and distal pulses were feebly palpable. Moreover, the skin colour returned to near normal with improvement of pallor. Bleeding was well controlled at the catheter site. Doppler sounds revealed partial improvement of arterial flow. After evaluation of partial improvement, a low dose 1000 iu per hour of heparin (UFH)was infused intravenously for 24 hours. After 48 hours, repeat angiography via the inserted catheter at the site did not reveal any atherosclerotic plaque and confirm the thrombosis-dissolution. The latter practice demonstrated a good blood flowto the left upper distal limb leaving a little thrombus in the superficial palmer arch. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): Catheter-based thrombus aspiration and thrombolytic therapy is primarily reserved for patients with acute viable limb ischemia. As observed in the presented case, thrombus aspiration and thrombolytic therapy is recommended to be considered as an alternative therapeutic method for patients with arterial thrombosis due to the rapid response, shorter treatment time and lower cost, compared to common and sometimes unsuccessful therapies.Copyright © 2023

A comparison of clinical management and treatment outcome of ischemic stroke prior to and during Covid- 19 pandemic in Hospital Universiti Sains Malaysia

Introduction: Covid-19 pandemic had significant impact on stroke care management and reduced the number of stroke admissions. A delay in treatment resulted in a more severe stroke with higher morbidity and mortality. Objective(s): To determine impact of Covid- 19 on the total number of admissions of stroke patients, compare ischemic stroke standard of care and outcome before and during Covid-19 pandemic. Methodology: A retrospective record review study. Data of patients with radiologically and - /or clinically confirmed AIS in HUSM who were diagnosed from 1st March 2019-28th February 2021 were recorded. Those who fulfilled the criteria were included in the study. Result(s): 229 patients were involved in this study;114 (49.8%) patients in the pre-Covid-19 period, and 115 (50.2%) patients during Covid-19 period. NIHSS score was similar, 5.3 +/- (4.18) in 2019 and 5.9 +/- (4.42) in 2020. There was no difference in terms of onset to door time between the two groups. However, we noticed a significant delay of onset to door time in both groups: 1875.2 min (31.25) hours in pre- Covid-19 vs. 1827.1 (30.45) hours during Covid-19 group (t. test 0.17, p = 0.863). The waiting time to see an ED (in minutes) dropped from 25.3 (30.21) during pre -Covid-19 period vs. 22.6 (16.48) in Covid- 19 group (t. test 0.48, p = 0.402). Door to CT brain time was 83.8 (58.91) vs 92.4 (120.20) during pre-Covid and Covid group (t. test -0.69, p = 0.493). There was a sharp decrease in patients who seek thrombolytic therapy from 7(6.1%) during pre-covid-19 to 4 (3.5%) during Covid-19 period (p = 0.354). As physiotherapy, occupational therapy, speech therapy assessment, the results are as follows;(77.2% vs. 81.7% p = 0.372), (76.3% vs. 81.7% p = 0.334), (50% vs. 59.1% p = 0.185), (43.9% vs. 45.2% p = 0.894) respectively. The duration of hospital stay was (6.4 +/- 4.5 vs. 7.5 +/- 6.74 (t. test -1.36, p = 0.175). MRS score at discharge was [2.8 (1.38) vs 2.9 (1.49)] (t. test -0.33 p = 0.742) for pre-Covid-19 and during Covid-19 group. Conclusion(s): The Covid-19 pandemic had no significant impact on stroke management and neurological outcomes for patients seeking treatment in HUSM.Copyright © 2023

Comparison of High-Risk Pulmonary Embolism Patients with and without COVID-19

Objectives: There has been a significant increase in pulmonary embolism (PE) cases during the coronavirus disease of 2019 (COVID-19) pandemic. In this study, we aimed to compare the effects of COVID-19 positivity on morbidity and mortality in patients treated with a diagnosis of high-risk PE. Method(s): In this single-center and observational study, patients who were referred to our center with the diagnosis of PE between January 1, 2019 and 2021 were retrospectively evaluated. Patients with moderate- and low-risk PE according to the European Society of Cardiology PE guidelines, those who did not undergo computed tomography pulmonary angiography (CTPA) or the ones who did not accept treatment were excluded from the study. The patients included in the study were divided into two groups, as those with and without COVID-19, and compared in terms of demographic data, comorbidities, symptoms, thromboembolism in vessels other than the pulmonary artery, laboratory parameters, treatments, and prognosis. Result(s): A total of 384 PE cases were identified during the study period. Among them, 322 cases that were in the intermediate or low-risk category, 21 cases who did not undergo CTPA, and one case who did not accept thrombolytic therapy were excluded from the study. A total of 40 cases were included in the study. The groups with and without COVID-19 consisted of 23 and 17 patients, respectively. In the group of patients with COVID-19, inflammatory markers were higher, Wells score was lower, and thromboembolism was seen in vessels other than the pulmonary artery. The two groups were similar in terms of other laboratory parameters, demographic data, comorbidities, symptoms, treatment, and prognosis. Conclusion(s): While the involvement of COVID-19 in PE etiology does not change mortality, it may cause more thrombosis development in both venous and arterial systems outside the pulmonary area by significantly increasing inflammation. However, the lower Wells scores in COVID-19 PE cases in our study indicate that new clinical assessment tools are needed to detect PE risk in COVID-19 patients.©Copyright 2022 by The Cardiovascular Thoracic Anaesthesia and Intensive Care.

Impact of COVID-19 on Acute Myocardial Infarction Care.

The global health crisis caused by the COVID-19 pandemic has evolved rapidly to overburden health care organizations around the world and has resulted in significant morbidity and mortality. Many countries have reported a substantial and rapid reduction in hospital admissions for acute coronary syndromes and percutaneous coronary intervention. The reasons for such abrupt changes in health care delivery are multifactorial and include lockdowns, reduction in outpatient services, reluctance to seek medical attention for fear of contracting the virus, and restrictive visitation policies adopted during the pandemic. This review discusses the impact of COVID-19 on important aspects of acute MI care.

Drip-and-ship toward mothership model for mechanical thrombectomy during COVID-19 pandemic: a retrospective analysis.

INTRODUCTION: During the first wave of the COVID-19 pandemic in spring 2020, our stroke network shifted from a drip-and-ship strategy (transport of acute ischemic stroke patients to the nearest primary stroke centers) toward a mothership model (direct transportation to the Comprehensive Stroke Center). We retrospectively analyzed stroke network performances comparing the two models. PATIENTS AND METHODS: All spoke-district patients treated with endovascular thrombectomy (EVT) between 15th March-15th June 2019 (drip-and-ship) and 2020 (mothership) were considered. We compared onset-to-groin time (OGT) and onset-to-needle time (ONT) between the two periods. Secondarily, we investigated other performances parameters (percentage of IV thrombolysis, timing of diagnostic and treatment) and clinical outcome (3-month modified Rankin Scale). RESULTS: Twenty-four spoke-district patients in 2019 (drip-and-ship) and 26 in 2020 (mothership) underwent EVT. The groups did not differ for age, sex, risk factors, pre-stroke mRS 0-1, NIHSS, and ASPECTS distribution. The MS model showed a significant decrease of the OGT (162.5 min vs 269 min, p = 0.001) without significantly affecting the ONT (140.5 min vs 136 min, p = 0.853), ensuring a higher number of IV thrombolysis in combination with EVT (p = 0.030). The mothership model showed longer call-to-door time (median + 23 min, p < 0.005), but shorter door-to-needle (median - 31 min, p = 0.001), and door-to-groin time (- 82.5 min, p < 0.001). We found no effects of the stroke network model on the 3-month mRS (ordinal shift analysis, p = 0.753). CONCLUSIONS: The shift to the mothership model during the COVID-19 pandemic guaranteed quicker EVT without significantly delaying IVT.

Massive Subchorionic Thrombohematoma and Maternal Cardiac Dysfunction: A Case Series

Background. Massive subchorionic thrombohematoma (MST), also known as Breus' mole, is a rare and poorly understood entity defined as a substantial collection of clotted blood in the intervillous space, immediately beneath the chorionic plate, measuring >1 cm in thickness with >50% involvement of the fetal surface of the placenta. The presumed pathophysiology is an aberrant collection of maternal blood, although this data is limited. MST has previously been associated with maternal thrombophilia and following thrombolytic therapy. Method(s): Four cases of MST diagnosed by pathological examination at our institution from 1/1/2021-7/1/2022 were identified using our laboratory information system. Maternal medical history, prenatal imaging, antenatal complications, gestation at delivery, and pregnancy outcome were extracted from the medical record. Result(s): We report a novel association of MST and maternal cardiac dysfunction, illustrated by four cases at a highrisk obstetric reference center covering a large portion of the southeastern United States. Two of these mothers had surgically repaired complex congenital heart disease, one had heart failure secondary to SARS-CoV-2 myocarditis, and one had longstanding high output heart failure due to severe sickle cell disease with resulting severe anemia. All of these pregnancies were complicated by intrauterine growth restriction (IUGR). Grossly, all four placentas had extensive fetal surface involvement by thrombohematoma (90-100%), but with variable degrees of placental volume replacement (range: 10-80%). Two of the four mothers had documented enoxaparin administration during pregnancy;however, there were no common medications given to all four mothers None had recognized thrombophilic disorders. Only one of four lesions was definitively identified on prenatal ultrasound. Of these four cases, three were live births, though only one infant survived past fifteen days of life. This surviving child had the least affected placenta grossly, was delivered at term, and was born to the only mother who did not require admission to the intensive care unit. Conclusion(s): We posit abnormal maternal hemodynamics are the final common pathway in the development of MST. Previous studies have shown blood within the thrombohematoma to be of maternal origin;furthermore, there is correlation within our case series between the largest lesions and the mothers with the most hemodynamic instability. IUGR is likely secondary to decreased placental reserve capacity from these space-occupying lesions. High fetal/neonatal morbidity and mortality rates underscore the need to further characterize this pathophysiologic process. That only one of four cases was detected on prenatal ultrasound illustrates the importance of both ante- and postnatal clinical and pathologic recognition.

Spontaneous hemothorax in a 48-year-old man with COVID-19 acute respiratory distress syndrome.

A 48-year-old man presented with gradually worsening dyspnea three days after testing positive for COVID-19. He was admitted to the intensive care unit on maximum high flow nasal cannula settings and subsequently intubated for hypoxic respiratory failure due to COVID-19 pneumonia. Two weeks into the patient's hospital course, he unexpectedly developed worsening hypotension with multiple vasopressor requirements. Labs revealed an unexpected hemoglobin drop from 12.5 to 7.9 g/dL. Chest radiograph showed near complete opacification of the right hemithorax concerning for hemothorax. This case presentation describes a rare phenomenon of spontaneous hemothorax in a patient with COVID-19.

Effects of COVID-19 pandemic in relation to stroke: Did the pandemic really change everything? A pre-post COVID-19 comparative study with literature review

Introduction and objectives: Ischemic stroke is the third leading cause of death and the first cause of disability in the world. Since March 2020, the COVID-19 pandemic has generated changes in daily medical practice, as well as an impact on access to health centers. The objective of this study is to evaluate the effect of the COVID-19 pandemic on the number of admissions, consultation time and treatment rates of stroke in our center. Material(s) and Method(s): Descriptive and retrospective study, with 115 patients between March 2019 and March 2021. Clinical characteristics, admissions time, severity and treatment rates pre-pandemic and during the same were compared. Result(s): Both groups presented mild events (71% vs. 59%, P > .05). There was an increase in the time from consultation to initiation of thrombolysis therapy during the pandemic (median 2.1 vs. 3.5 h, P = .02). No significant differences were observed in reperfusion rates, consultation time and door-to-needle time. Conclusion(s): In our study, a significant difference was observed between the time of symptom onset and treatment with thrombolysis during the pandemic. On the other hand, no significant differences were observed in relation to the number of admissions, consultation time and door-to-needle time or treatment rate of patients with stroke during the COVID-19 pandemic. We believe that this work can provide an approach to epidemiology in the private regional setting and a potential basis for further analysis of the collateral damage and long-term consequences generated by the COVID-19 pandemic. Copyright © 2022 Sociedad Neurologica Argentina

Successful Treatment of Paraplegia Caused by Venous Hypertension Secondary to Extensive Iliocaval Deep Venous Thrombosis in the Absence of Phlegmasia Cerulea Dolens

Objectives: Paraplegia is known to complicate extensive iliocaval and lower extremity deep vein thrombosis (DVT) in rare instances. The most common pathophysiology is ischemia from severe venous hypertension in phlegmasia cerulea dolens. Less understood, however, is paresis or paraplegia in the absence of ischemia. We present a case of paraplegia in extensive iliocaval and lower extremity DVT without ischemia, which was successfully treated by percutaneous pharmacomechanical therapy. Methods: A 46-year-old African American woman with a history of hypertension, insulin-dependent diabetes mellitus, indwelling inferior vena cava filter since 2005, and recent coronavirus disease 2019 diagnosis, presented with acute abdominal pain with severe bilateral lower extremity edema, pain, and paresis. She was found to have bilateral iliocaval to tibial DVT (Fig 1). The patient was noted to have multiphasic arterial waveforms on ankle-brachial index and duplex ultrasound examination. Paresis quickly progressed to flaccid bilateral lower extremity paralysis. Neurologic workup was unrevealing. Despite her symptoms, thrombolytic therapy was delayed due to severe menstrual bleeding requiring a blood transfusion. Therapeutic anticoagulation was initiated. Results: On hospital day 10, the patient underwent 24-hour catheter-directed thrombolysis via bilateral popliteal vein access. Bilateral mechanical thrombectomy was then performed, achieving recanalization of the bilateral lower extremities, iliac veins, and inferior vena cava with minimal residual thrombus (Fig 2). The patient's edema and sensorimotor function immediately improved and never incurred lower extremity tissue ischemia. She was discharged on lifelong rivaroxaban. With physical therapy, the patient ambulated independently at 1 month postoperatively. Venous duplex ultrasound examination revealed continued iliocaval and lower extremity patency at 6 months postoperatively. Conclusions: We postulate that this patient suffered lower extremity paralysis secondary to cauda equina syndrome. Pharmacomechanical thrombectomy is a pragmatic means that reestablishes venous patency and relieves venous hypertension. This pathophysiology and its treatment should be considered in extensive iliocaval DVT and lower extremity neurologic compromise despite duration of paralysis. [Formula presented] [Formula presented]

WAS COVID A “BLESSING IN DISGUISE?” MAY-THURNER SYNDROME COMPLICATES COVID

CASE: A 30-year-old previously healthy male presented with three weeks of progressively worsening pain, erythema, swelling in his left thigh, inability to bear weight and associated fatigue, fever, and dyspnea on exertion. Four weeks prior, he experienced 1 week of anosmia, fatigue, and “even worse” dyspnea on exertion with a resting heart rate in excess of 110 bpm and felt he most likely had had COVID. He self-treated for symptoms, rested, isolated and felt he had improved from COVID. The pain and swelling in the left leg increased over the prior three weeks and he sought care. On exam the left thigh was warm to touch, erythematous, and painful. Ultrasound imaging revealed left lower extremity deep venous thrombosis (DVT) extending from his upper thigh to lower leg. Abdominal/thoracic CT w/ contrast noted diffuse pulmonary emboli and May-Thurner Syndrome (MTS). Treatment was started with IV heparin followed by thrombolytic therapy with higher dose heparin and alteplase for 3 days. Shortly after this therapy was initiated, he developed significant hypoxia and was transferred to the ICU. He was stabilized and on the final day of thrombolytic therapy, a left common iliac vein stent was placed and he was discharged two days later on Apixaban and aspirin. IMPACT/DISCUSSION: May-Thurner syndrome (MTS), is an anatomical variant that may lead to venous outflow obstruction due to extrinsic compression by the iliac arterial system against bony structures in the iliocaval venous territory. Most common in the left leg, MTS is present in about 20% of the population and is more commonly found in women. It can result in venous hypertension and venous thromboembolisms (VTE). In serious and untreated cases, these VTEs can progress to pulmonary embolisms with resultant serious injury, hospitalization, and death. In this case, a recent COVID infection unearthed an MTS anomaly. The activated proinflammatory state induced by COVID is known to result in blood clots in hospitalized patients and appears to be related to a cytokine storm. This inflammatory state induces endothelial damage, microvascular thrombosis, and possibly pro-thrombotic antiphospholipid antibodies. In hospitalized patients with more severe disease VTE is commonly diagnosed, however the risk of COVID related coagulopathy in the outpatient setting is unknown. It appears that when blood clots do develop in outpatients, 1/5 have had a recent COVID infection which indicates an association between inflammation from infection contributes to VTE. In this case, the COVID complication helped to uncover a May-Thurner anomaly. CONCLUSION: - Delayed presentation can exacerbate COVID-related complications, even after acute symptoms have diminished - more should be done to educate patients on the dangers of post COVID thromboembolic disease. - Despite its prevalence in females, May-Thurners Syndrome should be in the differential for males with DVT.

Impact of COVID-19 on Acute Myocardial Infarction Care.

The global health crisis caused by the COVID-19 pandemic has evolved rapidly to overburden health care organizations around the world and has resulted in significant morbidity and mortality. Many countries have reported a substantial and rapid reduction in hospital admissions for acute coronary syndromes and percutaneous coronary intervention. The reasons for such abrupt changes in health care delivery are multifactorial and include lockdowns, reduction in outpatient services, reluctance to seek medical attention for fear of contracting the virus, and restrictive visitation policies adopted during the pandemic. This review discusses the impact of COVID-19 on important aspects of acute MI care.

ISCHEMIC AND THROMBOEMBOLIC VASCULAR COMPLICATIONS FOLLOWING COVID 19 VACCINATION

Background and aims: The initiation of a global mass vaccination against COVID-19 seems to decrease mortality and hospitalization for vaccinated people. However, side effects may occur. This short review illustrates some cases of vascular complications following the COVID-19 vaccination, affecting young people with ischemic, embolic complications or a combination of the two. Patients and methods: Observation 1: a 46 years old woman consulted for a sudden left sided hemiparesis seven days following the second dose of covid-19 vaccine. The initial brain scan was normal and she received thrombolytic treatment. Control scan showed signs of ischemic stroke of right superficial cerebral artery with haemorrhagic transformation. Supra-aortic ultrasound was performed showing a fresh mobile thrombus with complete obstruction of the right internal carotid artery. Observation 2: a 52 year old patient admitted for accute dyspnea, three days after receiving the third dose of covid-19 vaccine. CT angiography revealed a thrombosis of left pulmonary artery. Five days later, an ischemic vascular accident occurs confirmed by CT scan, so we made a supra-aortic ultrasound revealing a thrombosis of right proximal internal carotid artery. Discussion and results: Incidence of vascular complications due to the covid 19 vaccination is discussed with possible hypotheses. Conclusions: COVID-19 vaccines are considered safe since the proven benefits of vaccination in protecting against COVID-19. Nonetheless, health professionals must be aware of all possible complications, early diagnosis and quick initiation of the appropriate treatment may enhance the outcome. (Figure Presented).

PULMONARY THROMBECTOMY WITH CATHETER FOR THE TREATMENT OF ACUTE PULMONARY EMBOLISM: A LOCAL PROTOCOL

In February 2021, a PDTA on Pulmonary Embolism (PE) was approved in our hospital, including a chapter describing a protocol for the treatment with catheter thrombectomy (CT) of patients with high and intermediate risk PE. The protocol took into account the recommendations of the ESC 2019 guidelines on PE, and was produced to describe a path to improve the treatment of patients with PE It included: a) thrombectomy with aspiration in patients high-risk patients, with no haemodynamic improvement after administration of systemic thrombolytic therapy (TT) or with absolute contraindication to it;b) thrombectomy with loco-regional ultrasound-assisted thrombolysis (USAT) in patients at high-intermediate risk. 20 patients were treated from February 2020 to September 2021. 55% were men, with an average age of 73 ± 13 years;all patients met the criteria for inclusion in the protocol and signed a consensus document. 2 high-risk patients were treated with thromboaspiration: one patient for absolute contraindication to TT (recent spontaneous brain haemorrhage), the other one for a syncopal episode with head trauma. 18 patients (92%) at high intermediate risk were treated with USAT. For the 90% of patients were used 2 catheters;in 72% the administered dose of rt-PA was 24 mg. The mean value of NT- proBNP was 2,896 ng/l (normal m<93, f<144) There was only one major bleeding complication in the high-intermediate risk group (macrohematuria) during hospitalization. The mean RV/LV ratio was 1.48 (± 0.14) at baseline and 0.85 (± 0.14) at 48 hours with a reduction of 43%. The 2 high-risk patients died: one 1 month after the procedure, due to the effects of cerebral haemorrhage, the other one after 10 days due to respiratory complications. The mean FU of 17 patients was 228 days (± 193);during the FU there was a recurrence of PE (6%) after the discontinuation of anticoagulant therapy;there were no haemorrhages. RV dysfunction persisted in one patient (6%) with CTEPH who subsequently underwent pulmonary endarterectomy. Conclusion: PDTA and teamwork helped to improve the therapeutic decision making in patients with PE at a high and intermediate-high risk, despite the difficulties due to the SARS-COV-2 pandemic. Our experience was found to be in line with what has been published on the efficacy and safety of CT. (Figure Presented).

Trends, Treatment Approaches, and In-Hospital Mortality for Acute Coronary Syndrome in Japan During the Coronavirus Disease 2019 Pandemic.

AIM: The coronavirus disease 2019 (COVID-19) pandemic has left negative spillover effects on the entire health care system. Previous studies have suggested significant declines in cases of acute coronary syndrome (ACS) and primary percutaneous coronary intervention (PCI) during the COVID-19 pandemic. METHODS: We performed a quasi-experimental, retrospective cohort study of ACS hospitalisations by using a multi-institutional administrative claims database in Japan. We used interrupted time series analyses to ascertain impacts on cases, treatment approaches, and in-hospital mortality before and after Japan's state of emergency to respond to COVID-19. The primary outcome was the change in ACS cases per week. RESULTS: A total of 30,198 ACS cases (including 21,612 acute myocardial infarction and 8,586 unstable angina) were confirmed between 1st July 2018 and 30th June 2020. After the state of emergency, an immediate decrease was observed in ACS cases per week (-18.3%; 95% confidence interval, -13.1 to -23.5%). No significant differences were found in the severity of Killip classification (P=0.51) or cases of fibrinolytic therapy (P=0.74). The impact of the COVID-19 pandemic on in-hospital mortality in ACS patients was no longer observed after adjustment for clinical characteristics (adjusted odds ratio, 0.93; 95% confidence interval, 0.78 to 1.12; P=0.49). CONCLUSIONS: We demonstrated the characteristics and trends of ACS cases in a Japanese population by applying interrupted time series analyses. Our findings provide significant insights into the association between COVID-19 and decreases in ACS hospitalisations during the pandemic.

Stuck mechanical valve complication in non-COVID-19 patients during COVID-19 pandemic: single center experience

Background: Stuck valve is a very rare and severe complication that occurs in mechanical valve replacement patients with ineffective anticoagulation. However, with COVID-19 restriction measures, it became challenging to regularly assess INR to make sure it falls within the target therapeutic range to prevent this complication. Purpose: We wanted to explore how did the COVID-19 pandemic restrictions impacted mechanical valve replacement patients on chronic anticoagulation and the long-term consequences of limiting their access to health service. Methods: We present a series of 10 patients on warfarin anticoagulation therapy who either underwent transthoracic echocardiography for a suspected stuck valve or were seen at the outpatient valve clinic with the residual consequences of a stuck valve during the COVID-19 restriction measures in our institute. Results: Eight patients were female, two of whom were pregnant at the first trimester and eventually went on to receive an abortion;six patients received urgent valve replacement cardiac surgery;four patients were managed medically e.g. with heparin;none had thrombolytic therapy. Stuck prosthetic valves incident has increased significantly during this period, particularly those in the mitral position for which urgent replacement and prolonged hospitalization including intensive care admission, with high in-hospital mortality rates and high costs were necessary. Mean hospital admission time was 27.5 ± 18.5 days. The cost of treatment, as average estimated reimbursement, was 11,000 USD for medical admission only, and 43,200 USD when surgery was required, up to 64,000 USD when ECMO was part of patient management. Conclusion: Despite governments' efforts to implement telemedicine and virtual clinics, COVID-19 restrictions and health-messaging affected the routine follow-up of non-COVID-19 patients. We report dramatic consequences to this drastic change in healthcare: clinical complications, lost lives and inflated healthcare costs in patients with a prosthetic valve. We believe that non-COVID-19 patients have paid, and will continue to pay in the future, a price that is much greater than those patients who have suffered from COVID-19. Active engagement of patients should be implemented in a time of emergencies, and further studies should address the efficacy and cost-effectiveness of public policies aimed to decrease the burden of avoidable complications and missed diagnoses.

Acute pulmonary embolism in COVID-19 pandemic: prevalence and intrahospital outcome: a single center experience

Purpose: We want to evaluate clinical, laboratory profiles and intra-hospital outcome in patients with acute PE treated in intensive care unit in the period of COVID-19 pandemic. Methods: This is a single center, retrospective cohort study of patients with confirmed acute PE admitted in Intensive Cardiac Care Unit of a tertiary level university hospital between January and December 2020. Detailed history, risk factors, laboratory parameters and treatment strategy based on patient risk were assessed. All patients underwent 2-dimensional echocardiography, lower limb venous Doppler and CT pulmonary angiography (CTPA). sPESI score and intra-hospital outcomes were evaluated in all patients. Nasopharyngeal smear and realtime reverse transcriptase-polymerase chain reaction (RT-PCR) assay was performed in order to confirm COVID-19 infection. Results: We studied 47 patients with acute PE treated in our ICU, with mean age 58.6 ± 19.4 years. Eight patients (17%) had massive PE (central thrombus) and 39 (83%) had sub massive PE (subsegmental thrombus) confirmed by CTPA. Six patients (12,7%) had history of deep vein thrombosis (DVT), 3 patients (6,3%) had history of prior PE, 4 patients (8,5%) were operated within 3 months, 7 patients (14,8%) had history of malignancy, 24 patient's had increased body weight and obesity (51%). Twelve patients (25,5%) were tested for COVID 19 with real-time reverse transcriptase-polymerase chain reaction (RT-PCR) assay, and 3 come positive (12.5%). Eight patients were high risk with shock (17%), intermediate high risk were 29 patients (61.7%) and intermediate low risk were 10 patients (21.3%). sPESI score was >1 in all 47 patients. Abnormal RV function with PAH was found in 32 patients (68%). Five high risk, unstable patients died within 72 hours of admission, resulting in an overall ICU mortality rate of 10,6% and 62.5% mortality rate in patients with cardiogenic shock. Patients with PE and COVID-19 had significantly higher D-dimer and hs-Troponin I levels comparing to the patients with patients negative for COVID-19. Multivariate logistic regression analysis showed thrombolytic therapy OR 2.145 (95% CI: 1.105-4,512), D-Dimers >4.500 ng/ml OR 1.893 (95% CI: 0.932-3.241), high risk PE OR 3.98 (95% CI: 1.396-5.641) and acute renal failure OR 2.421 (95% CI: 1.105-4.762) as independent mortality predictors. Eight patients have been treated with fibrinolysis (t-PA), and 39 patients with Heparin therapy. 40 survived patients were discharged with NOAC treatment (95,2%). Conclusions: Pulmonary embolism cardiology clinic ICU admission in the period of COVID-19 pandemic decreased, with increase of PE severity, patients risk and mortality rate. Thrombolytic therapy, D-Dimers >4.500 ng/ml, high risk PE and acute renal failure were independent mortality predictors. Thrombolysis was successful treatment for high risk patients with low bleeding risk.

Thrombosis of Mechanical Mitral Valve Prosthesis Treated With Fibrinolysis

Background: Mechanical prosthetic valve thrombosis is an uncommon but serious complication associated with high mortality and morbidity. Conventionally, prosthetic valve thrombosis is treated with surgical intervention, but recent literature has shown that slow-infusion of low-dose fibrinolytic therapy could be of equal efficacy. Case: A 27-year-old lady presented to the emergency department with a three-week history of worsening shortness of breath on background of mechanical mitral valve replacement for rheumatic mitral stenosis. She had recently been non-compliant with international normalised ratio (INR) checks for warfarin dosing in the setting of local lockdown for the COVID-19 pandemic. Transthoracic echocardiography revealed mechanical mitral valve thrombosis resulting in an immobile medial disc and severely restricted lateral disc, associated with severely elevated mitral inflow gradient (mean 42mmHg at 98 beats per minute) and severe pulmonary hypertension (right ventricular systolic pressure of 92mmHg). After discussion in a multidisciplinary cardiology and cardiothoracic surgical conference, the patient was treated with three daily doses of slow-infusion low-dose fibrinolytic therapy (25mg alteplase over six hours). On day three, there was complete resolution of symptoms, associated with resolution of valve thrombosis on repeat echocardiography. There were no bleeding or embolic complications, and the patient was discharged home three days later. Conclusions: This case highlights the utility of slow-infusion low-dose fibrinolytic therapy in the management of mechanical prosthetic valve thrombosis. This conservative approach may be a useful alternative in patients with high pre-operative surgical risk.

Impact of SARS-CoV2 pandemic onto acute ST-elevation myocardial infarction care and patient outcomes in a large tertiary cardiac center

Background: SARS-CoV2 pandemic has caused major impact on patient care worldwide. We experienced a surge of cases beginning March 2020 leading to the government imposing a movement control order, more commonly known as 'lockdown' starting 18th March 2020. As such, various changes were implemented by our center to the clinical pathway for STEMI patients including using thrombolysis as the preferred initial treatment modality. Purpose: We aim to determine the impact of SARS-CoV2 pandemic on the clinical outcome of acute STEMI patients in our center which is a large regional tertiary hospital for cardiology. Methods and results: This is a single center retrospective cross-sectional study from 1st January 2020 until 31st May 2020. We compared clinical outcomes of patients admitted for acute STEMI before (group 1) and after (group 2) 15th March 2020 which is the date our center implemented changes to our STEMI care pathway. A total of 172 cases of acute STEMI was admitted to our center during this period. Admission for STEMI was noticeably lower after the lockdown implementation (group 1, n = 97 vs group 2, n = 75). The median time from symptom to presentation at our center did not differ between the two groups being 4.15h[2.78,7.28] vs 4.42h[2.97,8.01] p = 0.702, suggesting no outof- hospital delays in management. Majority of the patients in group 1 (n = 75, 77.2%) received primary percutaneous coronary intervention (PCI) vs only 17 (22.7%) in group 2. Most in group 2 (n = 54, 72%) received thrombolytic therapy and subsequently underwent coronary intervention within the same admission. This shows a shift in the preferred initial treatment modality for STEMI at our center during this period. The door to balloon time for patients undergoing primary PCI during this period was also numerically higher in group 2 but the difference was not statistically significant at 46min [38,63] vs 59min [45,72], p = 0.063, most likely due to the additional preparation needed in terms of SARS-CoV2 testing and personal protective equipment (PPE) prior to the procedure. The primary composite endpoint of in-hospital mortality and cardiogenic shock between the two groups (17.5% vs 24.3%, p = 0.275) did not show any significant difference. The incidence of inhospital mortality and cardiogenic shock were 4.1% vs 6.7% (p = 0.458) and 15.5% vs 21.9% (p = 0.281) respectively. Conclusions: This study suggests that thrombolysis as the preferred initial treatment modality for STEMI could be a reasonable temporary measure during the initial phase of a global pandemic to reduce infection risk of healthcare providers without compromising patient outcomes until adequate PPE and testing modalities are available for primary PCI to be performed safely. A follow-up study is needed to determine the long-term outcome of these patients.

Successful surgical-multimodal treatment for vaccine-induced complete splanchnic vein thrombosis after ChAdOx1 nCoV-19 vaccination

Objective Thrombotic-thrombocytopenic events are rare, but life-threatening, complications after ChAdOx1 nCoV-19 vaccination and sometimes present as symptomatic splanchnic vein thrombosis with critical illness. Life-saving aggressive and multimodal treatment is essential in these cases. Design We report on a critically ill 40-year-old male patient with complete splanchnic (portal/mesenteric/splenic) vein thrombosis, becoming symptomatic 7 days after ChAdOx1 nCoV-19 vaccination and diagnosed on day 12. Laparotomy for abdominal compartment syndrome and repeated transjugular/ transhepatic interventional and open surgical thrombectomy procedures were performed. Additional therapy consisted of thrombolysis with recombinant tissue-type plasminogen activator over 5 days, anticoagulation (argatroban), platelet inhibition (Acetylsalicylic acid /clopidogrel), immunoglobulins and steroids. Results This aggressive treatment included 5 laparotomies and 4 angiographic interventions, open abdomen for 8 days, transfusion of 27 units of packed red cells, 9 abdominal and 4 cerebral CT scans, thrombolysis therapy for 5 days, mechanical ventilation for 15 days, and an ICU stay of 25 days. Full patient recovery and near complete recanalization of splanchnic veins was achieved. Conclusion Without treatment, ChAdOx1 nCoV-19 vaccination-induced total splanchnic vein thrombosis has serious consequences with a high risk for death. The case described here shows that an aggressive multimodal surgical-medical treatment strategy in a specialized center can save these patients and achieve a good outcome.