Background We report a patient with COVID 19 who presented with STEMI and high thrombus burden, needing intracoronary (IC) alteplase infusion and subsequent PCI. Case 55 year old female with past history of diabetes, CVA (8 years back), recently diagnosed COVID 19 who presented to ED with chest pain for 18 hours. She was noted to have ST elevation in anterolateral leads and was taken for emergent angiogram. Angiogram showed large ostial LAD thrombus with thrombotic occlusion of distal LAD1. Decision-making Considering thrombus burden, several runs of aspiration thrombectomy was performed followed by balloon dilation. No distal flow was noted. Subsequently, 2 mg IC alteplase was infused twice, followed by thrombectomy. Repeat angiogram showed TIMI 0 flow. Intracoronary ultrasound (IVUS) was performed which showed heavy thrombus burden with no plaque rupture. PTCA of ostial LAD was performed afterwards with 4.0 x 15 mm compliant balloon. Thrombus was persistently noted in ostial LAD with TIMI 0 flow distally. She was started on aspirin, ticagrelor, heparin drip and 12 hour tirofiban infusion. 24 hours later she was taken back to the cath lab due to on and off chest pain and persistent ST elevation on EKG. Repeat angiogram showed persistent ostial LAD thrombus with TIMI 2 distal flow. PCI of ostial LAD was subsequently performed with excellent final result2. Conclusion IC alteplase can be considered in COVID patients with STEMI who have high burden burden when conventional measures fail to establish adequate flow. [Formula presented]
Use of Intracoronary Alteplase in a Covid Stemi Patient with Limited Distal Flow