Massive and submassive PE in patients with active Covid-19
This protocol is extracted from research article:
Pulmonary thrombosis in Covid-19: before, during and after hospital admission
J Thromb Thrombolysis, Jan 1, 2021; DOI: 10.1007/s11239-020-02370-7

As shown in Fig. 1, saddle PE (Fig. 2) occurred in four Covid-19 patients, even without substantial lung parenchymal involvement. Characteristics of these patients are described in Fig. 1. Regarding right heart catheterisation, normal ranges for right atrial pressure are 1–6 mmHg, for pulmonary arterial systolic pressure 15–29 mmHg and for cardiac index 2.4–4 L/min/m2 [12].

Characteristics of active Covid-19 patients with saddle/bilateral pulmonary embolism. CI cardiac index, CT computed tomography, CTPA computed tomography pulmonary angiography, Covid-19 Coronavirus disease 2019, FiO2 fractional inspired oxygen, PaO2 arterial oxygen partial pressure, PE pulmonary embolism, PEA pulseless electrical activity, RAP right atrial pressure, PASP pulmonary arterial systolic pressure, RHC right heart catheterisation RV/LV ratio – diameter of right ventricle divided by diameter of left ventricle measured at their wides midventricular point on axial images; yo-years old

Computed Tomography Pulmonary Angiography in a Covid-19 patient (patient 1), presented with saddle pulmonary embolism. a Saddle pulmonary embolism (red arrow) with emboli within the right (blue arrow) and left pulmonary artery (green arrow). b Large volume emboli extending into the more peripheral pulmonary arterial branches (red arrows). c Computed tomography features of right heart strain with flattening of the interventricular septum. Right Ventricular/Left Ventricular ratio is 1.43

Three of these patients were admitted directly from home (Fig. 1, patient 1, 3 & 4) while patient 2 developed PE after three days of hospitalization for Covid-19 pneumonia despite thromboprophylaxis (Figure (Figure1,1, patient 2).

PE early mortality risk was classified as intermediate-high in patients 1, 2 and 4, while PE early mortality risk was high in patient 3.

As per standard practice in our institution, all these patients underwent UACTD which minimizes tPA dosage (12 mg over 6 h, 6 mg each lung), potentially reducing the risk of haemorrhage into inflamed lungs [13, 14].

UACDT in this subpopulation was associated with a very rapid improvement in oxygenation. Three patients recovered from PE and were discharged, while one patient suffered from a pulseless electrical activity cardiac arrest during the eighth day of his hospitalization and died.

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