Obstructive Lung Diseases: Fellow Case Report Poster - Obstructive Lung Disease |

The Utility of Ultrasound and Multidisciplinary Teams for Management of Clot in Transit FREE TO VIEW

Sarun Thomas, DO; Aloke Chakravarti, MD; David Steiger, MD; Young Lee, MD
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Mount Sinai Beth Israel, New York, NY

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

Chest. 2016;150(4_S):904A. doi:10.1016/j.chest.2016.08.1004
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SESSION TITLE: Fellow Case Report Poster - Obstructive Lung Disease

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Right heart thrombus in transit(RHT) in patients with an acute pulmonary embolism(PE) is rare(3-4%), but associated with increased rate of deterioration and high mortality(13-37%). We present a case where early recognition with point of care ultrasound(POCUS), and activation of Pulmonary Embolism Response Team(PERT) lead to successful management in a patient with RHT.

CASE PRESENTATION: 48-year-old male frequent flyer to Peru with a recent history of a bleeding gastric ulcer presented with dyspnea. The patient was hemodynamically stable, with BP of 122/75mmHg, HR of 83 bpm. He was breathing 19 bpm with room air oxygen saturation of 97%. Initial troponin was 0.03ng/ml & BNP was 63pg/ml. A Chest CT angio showed an acute PE extending across the right and left main pulmonary arteries into lobar branches with signs of RV strain(Fig.1A). Pulmonary team performed POCUS which showed a large free floating RHT(Fig.1B) and bilateral deep vein thrombus(DVT). PERT was activated and the patient was seen by intensivists, cardiologists, interventional radiologists and cardiothoracic surgeons. TEE showed RHT with a patent foramen ovale(PFO)(Fig.1C). After interdisciplinary discussion, the patient received open pulmonary embolectomy(Fig.1D) with PFO closure and retrievable IVC filter placement. The patient was discharged after 8 days of hospitalization on therapeutic anticoagulation.

DISCUSSION: The optimal management of RHT in the context of an acute PE is challenging due to the absence of prospective studies comparing management options including anticoagulation, systemic thrombolysis, and endarterectomy. Meta-analyses suggest that outcome is improved with aggressive approaches due to the high risk of clinical deterioration. In our patient, the large mobile RHT with a PFO, the recent history of GI bleeding and the concomitant saddle PE and bilateral DVT with potential risk of hemodynamic deterioration prompted open thrombectomy. While traditional risk predictors would have stratified this hemodynamically stable patient with normal biomarkers as being at low risk for complications, the POCUS finding and the rapid PERT activation facilitated escalation of therapy for RHT.

CONCLUSIONS: This case illustrates the benefits of ultrasonography and early activation of a multidisciplinary team for the management of RHT.

Reference #1: Case Reports in Pulmonology.Volume 2012(2012),Article ID378282

Reference #2: Comparative efficacy of different modalities for treatment of right heart thrombi in transit:A pooled analysis;Athappan vascular medicine 2015

DISCLOSURE: The following authors have nothing to disclose: Sarun Thomas, Aloke Chakravarti, David Steiger, Young Lee

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