The first experience of treatment applied to patients with pulmonary embolism that developed on the COVID-19 background

The aim of the study was to evaluate the immediate results of treatment of high-risk PE developed against the background of COVID-19, and to analyze the features of the clinical course.
Material and methods. The study is based on the experience of treatment applied to three patients with pulmonary embolism (PE) that developed against the background of COVID-19. The group under consideration is represented by males. The average age was 41 ± 3.1 years old. Verification of the primary diagnosis of COVID-19 was based on positive results of polymerase chain reaction, supplemented by the results of computed tomography. The formation of high-risk PE was noted on the 5th–7th day from the moment of hospitalization. There was also a decrease in SO₂ below 85%, РаО₂ — below 76 mm Hg, Borg index > 8, which required non-invasive high-flow ventilation. Catheterization of the right chambers of the heart with a Swan–Ganz catheter revealed an increase in systolic pressure in the right ventricle to 57 ± 1.2 mm Hg, and diastolic pressure to 13 ± 0.34 mm Hg. Pulmonary hypertension increased up to 70 mm Hg. Changes in the biochemical analysis of blood consisted in increasing the level of troponin I to 0.65 ± 0.14 ng/ml, С reactive protein — to 5.42 ± 2.1 mg/l, and creatine phosphokinase — to 324 ± 23.1 units. An increase in the D-dimer level was observed (0.68 ± 0.11 mg/l). Systemic thrombolysis actilyse was performed in all the cases.
Results. Positive clinical dynamics was observed up to 15 hours after thrombolytic therapy. The level of SO₂ came back to the initial values and was in the range 93–96% and RaO₂ — from 86–92 mm Hg by the end of the first day after the intervention. The average pressure gradient in the pulmonary artery was 32 ± 4.12 mm Hg at the time of discharge, and at the peak — 44 ± 5.3 mm Hg.

1. Lu H., Stratton C.W., Tang Y.W. Outbreak of pneumonia of unknown etiology in Wuhan China: the mystery and the miracle. J. Med. Virol. 2020;92(4):401–2. DOI: 10.1002/jmv.25678.

2. World Health Organization (WHO). Novel coronavirus (2019-nCoV). Situation report. URL: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200207-sitrep-18-ncov.pdf?sfvrsn=fa644293_2

3. Coronaviridae Study Group of the International Committee on Taxonomy of Viruses The species severe acute respiratory syndromerelated coronavirus: classifying 2019-nCoV and naming it SARSCoV-2. Nat. Microbiol. 2020;5:536–544.

4. Lu R., Zhao X., Li J. et al. Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. Lancet. 2020;395(10224):565–574.

5. Delabranche X., Helms J., Meziani F. Immunohaemostasis: a new view on haemostasis during sepsis. Ann. Intensive Care. 2017;7(1):117.

6. Jackson S.P., Darbousset R., Schoenwaelder S.M. Thromboinflammation: challenges of therapeutically targeting coagulation and other host defense mechanisms. Blood. 2019;133(9):906–918.

7. Subramaniam S., Jurk K., Hobohm L. et al. Distinct contributions of complement factors to platelet activation and fibrin formation in venous thrombus development. Blood. 2017;129(16):2291–2302.

8. Noubouossie D.F., Reeves B.N., Strahl B.D., Key N.S. Neutrophils: back in the thrombosis spotlight. Blood. 2019;133(20):2186–2197.

9. Iba T., Levy J.H. Derangement of the endothelial glycocalyx in sepsis. J. Thromb. Haemost. 2019;17(2):283–294.

10. Varga Z., Flammer A.J., Steiger P. et al. Endothelial cell infection and endotheliitis in COVID-19 [published online ahead of print 20 April 2020]. Lancet. 2020;3 95(10234):1417–1418. DOI: 10.1016/S0140-6736(20)30937-5.

11. Iba T., Levy J.H., Thachil J., Wada H., Levi M. Scientific and Standardization Committee on DIC of the International Society on Thrombosis and Haemostasis. The progression from coagulopathy to disseminated intravascular coagulation in representative underlying diseases. Thromb. Res. 2019;179:11–14.

12. Oudit G.Y., Kassiri Z., Jiang C., Liu P.P., Poutanen S.M., Penninger J.M., Butany J. SARS coronavirus modulation of myocardial ACE-2 expression and inflammation in patients with SARS. Eur. J. Clin. Investig. 2009;39:618–625.

13. Ranucci M., Ballotta A., Di Dedda U. et al. The procoagulant pattern of patients with COVID-19 acute respiratory distress syndrome [published online ahead of print 17 April 2020]. J. Thromb. Haemost. 2020;18(7):1747–1751. DOI: 10.1111/jth.14854.

14. Stein P.D., Kayali F., Olson R.E., Milford C.E. Pulmonary thromboembolism in Asians/Pacific Islanders in the United States: analysis of data from the National Hospital Discharge Survey and the United States Bureau of the Census. Am. J. Med. 2004;116(7):435–442.

15. Schnittler H.J., Feldmann H. Viral hemorrhagic fever — a vascular disease? Thromb. Haemost. 2003;89(6):967–972.

16. Kloka F.A., Kruipb M.J.H.A., van der Meerc N.J.M. et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb. Res. 2020;191:145–147. DOI: 10.1016/j.thromres.2020.04.013.

17. Poissy J., Goutay J., Caplan M. et al. Pulmonary Embolism in COVID19 Patients: Awareness of an Increased Prevalence. Circula tion. 2020;142(2):184–186. DOI: 10.1161/CIRCULATIONAHA.120.047430

18. Llitjos J.F., Leclerc M., Chochois C., Monsallier J.M., Ramakers M., Auvray M., Merouani K. High incidence of venous thromboembolic events in anticoagulated severe COVID-19 patients. J. Thromb. Haemost. 2020;18(7):1743–1746. DOI: 10.1111/jth.14869

19. Wichmann D., Sperhake J.P., Lütgehetmann M., Steurer S., Edler C., Heinemann A., Heinrich F. et al. Autopsy Findings and Venous Thromboembolism in Patients With COVID-19: A Prospective Cohort Study. Ann. Intern. Med. 2020;173(4):268–277. DOI: 10.7326/M20-2003

20. Gibson C.M., Spyropoulos A.C., Cohen A.T. et al. The IMPROVEDD VTE Risk Score: Incorporation of D-Dimer into the IMPROVE Score to Improve Venous Thromboembolism Risk Stratification. TH Open. 2017;1(1):e56–e65. DOI: 10.1055/s-0037-1603929

21. Cohen A.T., Harrington R.A., Goldhaber S.Z. et al. For the APEX Investigators. Extended Thromboprophylaxis with Betrixaban in Acutely Ill Medical Patients. N. Engl. J. Med. 2016;375:534–44. DOI: 10.1056/NEJMoa1601747

22. Epidemiology Working Groupfor NCIP Epidemic Response The epidemiological characteristics of an out break of 2019 novel coronavirus diseases (COVID-19) in China. Chin. J. Epidemiol. 2020;41:145–151.

23. Zhou F., Yu T., Du R. et al. Clinical course and risk factors for mor tality of adult inpatients with COVID‐19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054–1062.