Cardiovascular Disease |

Heart Failure Precipitating Intraventricular Thrombi: A Devastating Result of Pulmonary Embolism From Oral Contraceptive Therapy in a Young Female FREE TO VIEW

Nina Kolbe, DO; Keith Killu, MD; Lisa Louwers, MD; Stephanie Bakey, DO; Dionne Blyden, MD; Mathilda Horst, MD
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Henry Ford Hospital, Detroit, MI

Chest. 2014;146(4_MeetingAbstracts):113A. doi:10.1378/chest.1991887
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SESSION TITLE: Cardiovascular Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Venous thromboembolism (VTE), specifically deep vein thrombosis (DVT) and pulmonary embolism (PE), are prevalent in the intensive care unit population. Pulmonary embolism can lead to devastating consequences of pulmonary hypertension and heart failure with improper treatment and poor follow-up.

CASE PRESENTATION: A 29 year old morbidly obese female (BMI 49) presented to the hospital with increased shortness of breath, 50lb weight gain in 6 months, and lower extremity pain. Her past history includes a pulmonary embolism after oral contraceptive therapy, for which she completed a 6 month course of warfarin five years ago. A genetic work-up for hypercoagulability was negative. Two years later the patient underwent an echocardiogram for increased lower extremity swelling and progressive dyspnea which demonstrated reduced right ventricular function, left ventricular ejection fraction (LVEF) of 35-40% and a pulmonary artery (PA) pressure of 70mmHg. One year later a repeat echocardiogram demonstrated a further reduced LVEF of 10-15% with continued elevated PA pressures and biventricular thrombi. The patient was prescribed carvedilol, furosemide, spironolactone, lisinopril, and warfarin, however did not take the medication due to cost. On her current admission a CT arteriogram demonstrated an occluded right femoral artery and an occluded left popliteal artery, as well as pulmonary emboli and biventricular thrombi. The patient was started on IV unfractionated heparin and her lower extremity symptoms improved. An echo again demonstrated a reduced LVEF of 15-20% with biventricular thrombi and reduced right ventricular function. The patient was given diuretic therapy, bridged to warfarin, and discharged home with follow-up.

DISCUSSION: Risk factors for VTE include oral contraceptive therapy which induces a hypercoagulable state, morbid obesity, congestive heart failure, and immobility. If left untreated, pulmonary embolism can lead to an increased pulmonary vascular resistance, and subsequently right heart failure. Stasis of intraventricular blood with a severely reduced ejection fraction and hypercoagulability can result in ventricular thrombi and an increased mortality. Oral anticoagulation is recommended for those patients with an intracardiac thrombus, an LVEF <35%, as well as patients with pulmonary embolism.

CONCLUSIONS: Venous thromboembolic events and their sequelae can have devastating outcomes in a young patient population. An awareness of risk factors, high index of suspicion, and prompt treatment with follow-up is crucial in treating these events.

Reference #1: Anderson F, Spencer F. Risk Factors for Venous Thromboembolism. Circulation 2003;107:9-16.

Reference #2: Lip GY, Ponikowski P, Andreotti F, et al. Thromboembolism and antithrombotic therapy for heart failure in sinus rhythm. European Journal of Heart Failure 2012;14(7):681-95.

Reference #3: Torbicki A, Galie N, Covezzoli A, et al. Right Heart Thrombi in Pulmonary Embolism. J Am Coll Card 2003;41(12)2245-2251.

DISCLOSURE: The following authors have nothing to disclose: Nina Kolbe, Keith Killu, Lisa Louwers, Stephanie Bakey, Dionne Blyden, Mathilda Horst

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