SESSION TYPE: Miscellaneous Cases II
PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: The short-term prognosis of pulmonary embolism (PE) depends on haemodynamic status of the patient. Risk stratification becomes very critical especially for normotensive patients. We present a case of submassive PE with concomitant right ventricle (RV) thrombus.
CASE PRESENTATION: 43 year-old male without any significant medical history who presented with two-week history of progressive dyspnea on exertion, chest tightness and right calf pain. Risk factors were obesity (BMI=42.4) and driving 416 miles days before symptom onset. Physical examination revealed an obese male with increased work of breathing. He was normotensive with a heart rate of 128, respiratory rate of 22 and oxygen saturation of 95% on 2 Liters of oxygen. His lungs were clear to auscultation bilaterally in all fields and cardiac exam was pertinent for a loud S3 gallop. He had a non-erythematous, swollen and tender right calf. Chest computed tomography with intravenous contrast revealed extensive emboli in the proximal branches of his pulmonary artery (Figure 1). Doppler ultrasound of his right lower extremity showed a deep vein thrombosis. Surface echocardiogram showed RV strain and free-wall hypokinesis, RV systolic pressure of 78mmHg, right atrium pressure of 20mmHg and a large RV thrombus (Figure 2). EKG pattern confirmed sinus tachycardia with an S1, Q3, T3 morphology and right-axis deviation. Admission labs were remarkable for troponin 0.37, BNP 629pg/mL, D-dimer 8934ng/mL, alkaline phosphatase 95unit/L, ALT 76unit/L and AST 51unit/L. He was immediately bolused with unfractionated heparin and continued on an infusion prior to being transferred to the medical ICU. Given his significant clot burden in both the pulmonary circulation and RV, pulmonary embolectomy was considered, however we elected to administer 24-hour continuous systemic thrombolytic therapy through a pulmonary artery catheter. He developed mild epistaxis which did not require interruption of thrombolytic infusion. He remained hemodynamically stable with improvement of his tachycardia and dyspnea. His troponin, liver transaminases and BNP improved suggesting improvement of RV strain. Maximum D-dimer value was >15,000ng/mL after thrombolytic infusion which was attributed to clot dissolution.
DISCUSSION: Our case illustrates the complex decision making regarding aggressive medical versus surgical treatment strategies in managing a normotensive patient with submassive PE and large RV thrombus. It also highlights the need for risk stratification of confirmed acute PE.
CONCLUSIONS: Prompt administration of continuous systemic thrombolytics resulted in improved morbidity and mortality in our patient.
1) Sanchez O, Trinquart L, Colombet I, et al. Prognostic value of right ventricular dysfunction in patients with haemodynamically stable pulmonary embolism: a systematic review. European heart journal 2008; 29:1569-1577
DISCLOSURE: The following authors have nothing to disclose: Milan Patel, Timothy Udoji, Kenneth Leeper
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