The debate regarding treatment of massive pulmonary embolism (PE) with thrombolytic agent is ongoing and clear cut indications still lacking and what makes the decision even harder is the presence of right side heart thrombemboli. Massive pulmonary embolism and hemodynamic instability still the most definite indication for thrombolytics therapy even though there is no strong evidence to support this approach.CASE REPORT: A 73-year-old woman admitted to our hospital with left leg pain and sudden onset of shortness of breath. She has a past medical history of left breast cancer treated with mastectomy, radiation therapy and chemotherapy.Physical exam revealed a blood pressure of 122/76, heart rate of 113 beat per minute, respiratory rate of 24-30 and an O2 Sat of 86% on room air (RA). Electrocardiogram shows a sinus tachycardia with left ventricular hypertrophy. Chest radiograph reveals left side pleural effusion. Spiral computer tomograph (CT) of the chest demonstrated a right pulmonary artery thrombus extending to upper, middle and lower lobe branches.A transthoracic echocardiogram (ECHO) shows a large amorphous mobile thrombus in the left atrium prolapsing through the mitral valve into the left ventricle during systole and protruding across aneuryismal intraatrial septum into the right ventricle. The right atrium appeared to be hypokinetic and there was a decrease left ventricular dysfunction. A Doppler ultrasound of the lower extremities was negative for deep venous thrombosis.After placement of vena cava filter the decision was made to thrombolize the patient with tissue plasminogen activator and she was monitored in our intensive care unit. Unfractioned heparin was started after the thrombolytic infusion. Four hours after thrombolysis the patient became aphasic and develops right-sided weakness. Subsequent CT of the head reveals an ischemic stroke.A repeat ECHO demonstrated the disappearance of the thrombus and improved right ventricular function. The patient saturation improved to 94% on RA.Patient neurological status improved and she was started on coumadin and transferred to inpatient rehabilitation facility.DISCUSSION: The increased use of ECHO in patients with PE resulted in more frequent identification of right-sided heart thrombemboli, with reported incidence of 3% to 23%(1).The majority are found in the right atrium. Most report recommends aggressive treatment as discussed below.In our case the thrombus was going through intraatrial septum to the left atrium into the left ventricle which poses the risk for paradoxical emboli. Therapeutic options in this case were 1. Anticoagulation 2. Thrombolytic therapy with anticoagulation 3. Surgical removal of the thrombus. Recent review identified 177 patients with right hear thrombemboli reported an overall mortality rate of 27%. The mortality rates in patients treated with anticoagulation, surgery, or thrombolytic therapy were 28.6%, 23%, and 11.3%, respectively(2). Our consensus was to use thrombolytic agent taking into account that the benefit would overweight the risk of motility from the massive PE.Anticoagulation remains the standard of care for venous thrombembolism which prevent clot propagation. Thrombolytic therapy, in contrast, produces more rapid clot lysis and may result in earlier improvement in pulmonary perfusion, hemodynamics, gas exchange, and right ventricular function
The American College of Chest Physicians consensus statement on antithrombotic therapy published in 2001 outlined appropriate regimen for the use of thrombolytic agent. There was a continued emphasis that the use of these agents should be highly individualized. Our patient could have been managed differently depending on different approach, experience and available resources.
H.A. Haddadin, None.