Thrombolysis and use of argatroban for the treatment of massive pulmonary embolism following anticoagulation failure in a patient with COVID-19

Purpose. Successful use of alteplase and argatroban to treat a patient with coronavirus disease 2019 (COVID-19)-associated massive pulmonary embolism with cardiac arrest is reported. Summary. This case report describes a 42-year-old male with COVID-19 who developed a massive pulmonary embolism resulting in cardiac arrest after suspected failure of low-molecular-weight heparin therapy for a deep venous thrombosis. Administration of two 50-mg doses of intravenous alteplase resulted in return of spontaneous circulation, and low-dose argatroban was used as follow-up anticoagulation therapy without complications. This is the first case report of use of argatroban in a patient with COVID-19 with cardiac arrest-associated massive pulmonary embolism after failure of previous anticoagulation efforts. Conclusion. Argatroban may be used as an alternate anticoagulation strategy in COVID-19 patients who fail low-molecular weight therapy. A risk versus benefit discussion should be had regarding appropriateness of therapy as well as dosing. More data is needed to understand the unique hypercoagulable condition in COVID-19 patients as well as research that further highlights the role of argatroban and bivalirudin therapy in this patient population.