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A Woman in Her 70s With Profound Hypoxemia FREE TO VIEW

Joseph P. Mathew, MD, FCCP; Ismini Kourouni, MD; Shaun Noronha, MD; Gopal Narayanswami, MD, FCCP; Janet M. Shapiro, MD, FCCP
Author and Funding Information

aDivision of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai St. Luke’s and Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY

bDepartment of Medicine, Mount Sinai St. Luke’s and Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York, NY

CORRESPONDENCE TO: Ismini Kourouni, MD, Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai St. Luke’s and Mount Sinai West, Icahn School of Medicine at Mount Sinai, 1111 Amsterdam Ave–Muhlenberg 316, New York, NY 10025


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;150(1):e13-e17. doi:10.1016/j.chest.2016.02.688
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Published online

A woman in her 70s was admitted to our institution with symptoms of transient confusion, aphasia, and right arm weakness. Her medical history was notable for breast cancer (for which she had received chemotherapy in 2001), paroxysmal atrial fibrillation, and a history of pulmonary embolus in 2002 (for which she underwent 3 months of warfarin treatment). She also reported a history of chronic postmenopausal vaginal bleeding due to uterine fibroids. An MRI of the brain revealed a small area of infarct in the left insular cortex/corona radiata. Transesophageal echocardiography revealed normal left and right ventricular (RV) function and a moderate-sized atrial septal defect (ASD) with bidirectional shunt. A CT scan of the abdomen and pelvis revealed a heterogeneously enhancing 25 × 25 × 25 cm pelvic mass of uterine origin, suspicious for leiomyosarcoma (Fig 1).

Figure Jump LinkFigure 1 CT scan of the abdomen and pelvis without contrast: 25 × 25 × 25 cm heterogeneously enhancing mass in the pelvis, extending to the upper abdomen, likely uterine in origin.Grahic Jump Location

On hospital day 8, the rapid response team was called for profuse vaginal bleeding, but the patient was hemodynamically stable and thus remained on the general medicine service. Two days later, the rapid response team was again called after the patient was found to be hypoxic during the night shift. The patient’s vital signs were as follows: temperature 37.6°C; BP 139/72 mm Hg; heart rate 103 beats/min; respiratory rate 24 breaths/min; and oxygen saturation 72% on room air. She was relatively asymptomatic and denied dyspnea, chest pain, or dizziness. She appeared comfortable despite the low oxygen saturation. Her physical examination revealed normal heart sounds and clear breath sounds bilaterally with no wheezing. Chest radiograph revealed clear lung fields (Fig 2), and an ECG showed new incomplete right bundle branch block and S1Q3T3 pattern (Fig 3). Bedside-focused critical care ultrasonography was performed to evaluate the etiology of her hypoxemia.

Figure Jump LinkFigure 2 Chest radiograph showing clear lung fields.Grahic Jump Location

Figure Jump LinkFigure 3 Normal sinus rhythm, new incomplete right brunch block, S1Q3T3 pattern.Grahic Jump Location

Question: Based onVideo 1, the ECG, and the patient’s clinical presentation, what is the most likely diagnosis?

Answer: Pulmonary embolism with clot in transit.

The patient’s clinical presentation and ECG findings are highly suggestive of pulmonary embolism (PE). Bedside goal-directed echocardiography (GDE) revealed a large mobile mass in the right ventricle adherent to the tricuspid valve apparatus and protruding into the RV outflow tract (Video 2). The right ventricle appeared dilated and hypokinetic with basal septal bulging into the left ventricle; left ventricular function appeared normal. Color Doppler imaging revealed continuous flow across the interatrial septum. Lower extremity compression ultrasound revealed no DVT in the femoral or popliteal veins.

These findings are consistent with submassive PE with “clot-in-transit,” as demonstrated by the mobile echodensity seen in the right ventricle. There was evidence of RV dilation and hypokinesis. The patient also has a right-to-left shunt, as demonstrated by color Doppler imaging. This finding explains her initial presentation to the hospital with neurologic symptoms, as she likely had paradoxical thromboemboli to the brain. The shunt is contributing to the patient’s severe hypoxemia as well. However, she had relative contraindications to systemic thrombolytic therapy, including significant vaginal bleeding 2 days earlier. There was also concern for further embolic stroke with both systemic and catheter-directed thrombolysis.

PE is a life-threatening emergency that carries a mortality rate of up to 58% if it is not diagnosed in a timely fashion. Point-of-care cardiac, thoracic, and vascular ultrasonography is increasingly being used for the diagnosis and management of patients with PE.,, Focused lower extremity compression ultrasound by intensivists has been shown to accurately diagnose DVT. Among patients with large PE, findings on GDE include RV dilation, RV hypokinesis, flattening and paradoxical motion of the interventricular septum, tricuspid regurgitation, and lack of collapse of the inferior vena cava with inspiration. The RV diameter is larger than the left ventricular diameter, with evidence of decreased RV contractility. McConnell’s sign, in which there is severe RV free wall hypokinesis along with hypercontractility of the RV apex, can be seen with acute PE; however, it may also be detected in RV myocardial infarction.

Previous research shows that these echocardiographic features have high specificity in patients in whom there is a high suspicion for PE, but they lack sensitivity. In patients suspected of having PE, a combination of GDE, thoracic ultrasound, and vascular ultrasound of the lower extremities has been shown to reduce the need for CT pulmonary angiograms (CTPA), as well as provide an alternative diagnosis. Similarly, point-of-care multiorgan ultrasound (thoracic, cardiac, and vascular) has a sensitivity of 90% and a specificity of 86% for diagnosing PE in patients with suspected PE. Single-organ ultrasound is specific but lacks sensitivity. Hence, GDE alone should not be used as a test to diagnose PE because most patients with PE have normal echocardiograms.

Echocardiography is excellent for risk-stratifying patients who are at higher risk for death. GDE can often facilitate a change in management and monitoring, based on early detection of patients who have a higher likelihood of hemodynamic instability and death. RV dysfunction has been well established as a predictor of worse outcomes. In patients with large PE, detection of a patent foramen ovale predicts a higher risk of death and thromboembolic complications such as stroke. In patients with free-floating right heart thrombi, as in the present patient’s case, the mortality rate was as high as 45% in 1 series. Echocardiography can also be useful in reassessing right heart thrombi after systemic thrombolytic therapy to ensure dissolution of the thrombi. In addition, in patients with unstable disease who cannot undergo CTPA or for patients following cardiac arrest, transesophageal echocardiography is another modality to diagnose PE.

The study patient was started on unfractionated heparin and transferred to the ICU. Her oxygenation improved with high-flow nasal cannula. In light of the patient’s high risk of mortality and embolic stroke, cardiothoracic surgery was consulted, and a decision was made to perform surgical pulmonary embolectomy and closure of the ASD. CTPA was performed the next day, confirming extensive PE (Fig 4). Repeat GDE revealed persistent mobile thrombi in the right heart. The patient remained hemodynamically stable up until the surgery the following morning, when she developed hypotension. Fortunately, the pulmonary embolectomy and ASD closure were successful (Fig 5). Results of uterine biopsies were nondiagnostic, and the patient was to follow up for further evaluation of the pelvic mass. She was discharged home on warfarin after brief stays in the cardiothoracic ICU and acute rehabilitation service.

Figure 4
Figure Jump LinkFigure 4 CT angiogram of the chest. Extensive pulmonary emboli noted with tubular serpiginous clot noted in main pulmonary artery with saddle embolus.Grahic Jump Location
Figure 5
Figure Jump LinkFigure 5 Large soft, brown and dark red, elongated and cylindrical pieces of tissue consistent with clot, measuring 0.1 to 1.3 cm in diameter, with a total length of 24.5 cm.Grahic Jump Location

The present case demonstrates the critical role of bedside GDE in the rapid diagnosis and management of a patient with submassive PE, ASD, and mobile thrombi in transit. Bedside point-of-care ultrasonography is a valuable tool that can quickly provide critical information on the physiologic effect of PE on the right ventricle. It can help risk-stratify the patient and direct therapy toward systemic or catheter-directed thrombolysis and surgical embolectomy.

  • 1.

    Cardiac ultrasonography can be combined with thoracic and lower extremity compression ultrasonography to assess the patient with suspected PE and to help find alternative diagnoses.

  • 2.

    GDE can diagnose complications of PE such as mobile clots in the right heart and RV strain. Color Doppler imaging can be used to assess for atrial septal defects.

  • 3.

    McConnell's sign is a distinct echocardiographic finding described in patients with acute PE; there is a distinct regional pattern of RV dysfunction, with akinesia of the mid-free wall but normal or hyperdynamic motion at the apex. This finding can also be seen in RV infarction.

  • 4.

    Echocardiography can be used to further risk-stratify patients with PE and guide the next steps of treatment such as thrombolytic therapy or surgical embolectomy.

Author contributions: J. P. M. helped acquire the images, edit the video, and write the manuscript; I. K. and J. M. S. helped acquire the images and write the manuscript; and S. N. and G. N. helped edit the video and write the manuscript.

Financial/nonfinancial disclosures: None declared.

Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online version of this article.

Goldhaber S.Z. .Visani L. .DeRosa M. . Acute pulmonary-embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999;353:1386-1389 [PubMed]journal. [CrossRef] [PubMed]
 
Goldhaber S. . Echocardiography in the management of pulmonary embolism. Ann Intern Med. 2002;136:691-700 [PubMed]journal. [CrossRef] [PubMed]
 
Koenig S. .Chandra S. .Alaverdian A. .Dibello C. .Mayo P. .Narasimhan M. . Ultrasound assessment of pulmonary embolism in patients receiving CT pulmonary angiography. Chest. 2014;145:818-823 [PubMed]journal. [CrossRef] [PubMed]
 
Dresden S. .Mitchell P. .Rahimi L. .et al Right ventricular dilatation on bedside ultrasonography performed by emergency physicians aids in the diagnosis of pulmonary embolism. Ann Emerg Med. 2014;63:16-24 [PubMed]journal. [CrossRef] [PubMed]
 
Kory P.D. .Pellecchia C.M. .Shiloh A.L. .Mayo P.H. .DiBello C. .Koenig S. . Accuracy of ultrasonography performed by critical care physicians for the diagnosis of DVT. Chest. 2011;139:538-542 [PubMed]journal. [CrossRef] [PubMed]
 
Casazza F. .Borgarzoni A. .Capozi A. .Agostoni O. . Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction. Eur J Echocardiogr. 2005;6:11-14 [PubMed]journal. [CrossRef] [PubMed]
 
Nazerian P. .Vanni S. .Volpicelli G. .et al Accuracy of point-of care multi-organ ultrasonography for the diagnosis of pulmonary embolism. Chest. 2014;145:950-957 [PubMed]journal. [CrossRef] [PubMed]
 
Konstantides S.V. .Torbicki A. .Agnelli G. .et al 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) Endorsed by the European Respiratory Society (ERS). Eur Heart J. 2014;35:3033-3073 [PubMed]journal. [CrossRef] [PubMed]
 
Konstantinides S. .Geibel A. .Kasper W. .Olschewski M. .Blumel L. .Just H. . Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation. 1998;97:1946-1951 [PubMed]journal. [CrossRef] [PubMed]
 
Chartier L. .Béra J. .Delomez M. .et al Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation. 1999;99:2779-2783 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 CT scan of the abdomen and pelvis without contrast: 25 × 25 × 25 cm heterogeneously enhancing mass in the pelvis, extending to the upper abdomen, likely uterine in origin.Grahic Jump Location
Figure Jump LinkFigure 2 Chest radiograph showing clear lung fields.Grahic Jump Location
Figure Jump LinkFigure 3 Normal sinus rhythm, new incomplete right brunch block, S1Q3T3 pattern.Grahic Jump Location
Figure Jump LinkFigure 4 CT angiogram of the chest. Extensive pulmonary emboli noted with tubular serpiginous clot noted in main pulmonary artery with saddle embolus.Grahic Jump Location
Figure Jump LinkFigure 5 Large soft, brown and dark red, elongated and cylindrical pieces of tissue consistent with clot, measuring 0.1 to 1.3 cm in diameter, with a total length of 24.5 cm.Grahic Jump Location

Tables

References

Goldhaber S.Z. .Visani L. .DeRosa M. . Acute pulmonary-embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet. 1999;353:1386-1389 [PubMed]journal. [CrossRef] [PubMed]
 
Goldhaber S. . Echocardiography in the management of pulmonary embolism. Ann Intern Med. 2002;136:691-700 [PubMed]journal. [CrossRef] [PubMed]
 
Koenig S. .Chandra S. .Alaverdian A. .Dibello C. .Mayo P. .Narasimhan M. . Ultrasound assessment of pulmonary embolism in patients receiving CT pulmonary angiography. Chest. 2014;145:818-823 [PubMed]journal. [CrossRef] [PubMed]
 
Dresden S. .Mitchell P. .Rahimi L. .et al Right ventricular dilatation on bedside ultrasonography performed by emergency physicians aids in the diagnosis of pulmonary embolism. Ann Emerg Med. 2014;63:16-24 [PubMed]journal. [CrossRef] [PubMed]
 
Kory P.D. .Pellecchia C.M. .Shiloh A.L. .Mayo P.H. .DiBello C. .Koenig S. . Accuracy of ultrasonography performed by critical care physicians for the diagnosis of DVT. Chest. 2011;139:538-542 [PubMed]journal. [CrossRef] [PubMed]
 
Casazza F. .Borgarzoni A. .Capozi A. .Agostoni O. . Regional right ventricular dysfunction in acute pulmonary embolism and right ventricular infarction. Eur J Echocardiogr. 2005;6:11-14 [PubMed]journal. [CrossRef] [PubMed]
 
Nazerian P. .Vanni S. .Volpicelli G. .et al Accuracy of point-of care multi-organ ultrasonography for the diagnosis of pulmonary embolism. Chest. 2014;145:950-957 [PubMed]journal. [CrossRef] [PubMed]
 
Konstantides S.V. .Torbicki A. .Agnelli G. .et al 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC) Endorsed by the European Respiratory Society (ERS). Eur Heart J. 2014;35:3033-3073 [PubMed]journal. [CrossRef] [PubMed]
 
Konstantinides S. .Geibel A. .Kasper W. .Olschewski M. .Blumel L. .Just H. . Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation. 1998;97:1946-1951 [PubMed]journal. [CrossRef] [PubMed]
 
Chartier L. .Béra J. .Delomez M. .et al Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation. 1999;99:2779-2783 [PubMed]journal. [CrossRef] [PubMed]
 
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