We describe successful usage of low dose Tissue plasminogen activator (tPA) (30-50 mg) in three COVID19 critically ill patients, who were in worsening respiratory failure in-spite of being on therapeutic anticoagulation. All patients had respiratory rate > 40; FiO 2 > 0.7(on NIV); PiO 2 /FiO 2 ratio < 100 and D-dimer>1000 ng/ml. C.T. Pulmonary Angiography could not be done in these patients due to poor general condition, but 2D echo was normal 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. All patients became off oxygen within 3-7 days and were discharged within 2 weeks. The whole idea was to prevent intubation, since mortality rates are very high in intubated COVID19 patients. tPA is associated with <1% risk of fatal bleed. In this unprecedented pandemic with high mortality rates, thrombolysis could be an effective and safe option in carefully selected critically ill patients of COVID19. Keywords Thrombolysis • COVID19 • Acute respiratory distress syndrome (ARDS) • Coagulopathy • Tissue plasminogen activator (tPA) Highlights• COVID19 related coagulopathy can cause extensive pulmonary micro thrombosis leading to ARDS and is one of the most important reasons for mortality. • We report three cases of COVID-19 disease who were in severe ARDS (PiO 2 /FiO 2 ratio < 100) and were on the verge of intubation. • Although no evidence of PTE was present on 2D echo, thrombolysis was done with low dose tPA; all patients had significant improvement and became off oxygen within 3-7 days.• Thrombolysis could be an effective and safe option in carefully selected critically ill patients of COVID19 ARDS and can prevent mortality.

Introduction OSA has been postulated to be associated with mortality in COVID-19, but studies are lacking thereof. This study was done to estimate the prevalence of OSA in patients with COVID-19 using various screening questionnaires and to assess effect of OSA on outcome of disease. Methodology In this prospective observational study, consecutive patients with RT-PCR confirmed COVID-19 were screened for OSA by different questionnaires (STOPBANG, Berlin Questionnaire, NoSAS, and Epworth Scale). Association between OSA, outcome (mortality) and requirement for respiratory support was assessed. Results In study of 213 patients; screening questionnaires for OSA [STOPBANG, Berlin Questionnaire (BQ), NoSAS] were more likely to be positive in patients who died compared to patients who survived. On binary logistic regression analysis, age ≥ 55 and STOPBANG score ≥ 5 were found to have small positive but independent effect on mortality even after adjusting for other variables. Proportion of patients who were classified as high risk for OSA by various OSA screening tools significantly increased with increasing respiratory support ( p < 0.001 for STOPBANG, BQ, ESS and p = 0.004 for NoSAS). Conclusion This is one of the first prospective studies of sequentially hospitalized patients with confirmed COVID-19 status who were screened for possible OSA could be an independent risk factor for poor outcome in patients with COVID-19.

Management of a pregnant patient with mechanical heart valve is a complex issue for all health care providers involved in the care of such patients. Complications may arise at any stage due to the increased haemodynamic load imposed by pregnancy or because of impaired cardiac performance often seen in these patients. In addition, the use of various cardiovascular drugs in pregnancy (especially anticoagulants) may lead tofoetal loss or teratogenic complications. Additionally, the risk of thrombo-embolic complications in the mother is increased by the hypercoagulable state of pregnancy. In this review, we have attempted to draw inferences to guide management of such patients based on the available literature. It seems that in pregnant women with mechanical heart valves, recent data support warfarin use throughout pregnancy, followed by a switch to heparin and planned induction of labour. However, the complexity of this situation demands a cafeteria approach where the patient herself can choose from the available options that are supported by evidence-based information. Unfortunately there is no consensus on such data. An overview of the available literature forms the basis of this review. In conclusion, a guideline comprising pragmatic considerations is preffered.

Patients with congenitally unguarded tricuspid valve orifice, along with associated abnormalities, rarely survive till adulthood. We report such a case, with a hypoplastic right ventricle and a floating thrombus in a giant right atrium, with intact interatrial and interventricular septa. The patient was managed surgically with satisfactory outcome. (Ind J Thorac Cardiovasc Surg, 2007; 23: 272-274)

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.