Pulmonary Vascular Disease: Student/Resident Case Report Poster - Pulmonary Vascular Disease II |

Pulmonary Endarterectomy for Submassive Septic Pulmonary Embolism FREE TO VIEW

Benjamin Shieh, MD; Sean Gilman, MD
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McGill University, Montreal, QC, Canada

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

Chest. 2016;150(4_S):1223A. doi:10.1016/j.chest.2016.08.1332
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SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Vascular Disease II

SESSION TYPE: Student/Resident Case Report Poster

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

INTRODUCTION: Septic pulmonary emboli (PE) rarely occlude the main pulmonary arteries. There is no standard approach to treatment when this occurs. To our knowledge, pulmonary endarterectomy has not been attempted in a patient with submassive (American Heart Association definition for PE severity) septic PE.

CASE PRESENTATION: An 18 year old female presented with pleuritic chest pain, shortness of breath and fever. She was diagnosed 6 weeks earlier with group B streptococcus right-sided endocarditis following a dilatation and curettage procedure/Mirena intra-uterine device insertion. Despite medical management with IV antibiotics, her clinical status was deteriorating. A computed tomography scan of the chest demonstrated a large filling defect in the distal right pulmonary artery, with involvement of the interlobar artery and segmental branches of the right middle, right lower, and left lower lobes. A trans-thoracic echocardiogram revealed an increased PASP at 46mmHg and the disappearance of 2 vegetations (18.3x15.6mm and 17.6x9.3mm previously seen on her tricuspid valve). Her Troponin-I level was elevated at 3.41 (Normal range ≤0.04). She was brought to the OR and underwent a right pulmonary endarterectomy with removal of occlusive material. Pathology of the excised thromboembolism demonstrated thrombus and purulent exudate within an acutely inflamed arterial wall. She was placed on 6 weeks of additional antibiotic therapy and 6 months of oral anticoagulation. At follow up 6 weeks post-operation, she was clinically well with no signs of ongoing sepsis or recurrent emboli.

DISCUSSION: The composition of septic PE is likely different from thrombo-emboli, making the use of standard treatments for PE unclear in the submassive setting. Anticoagulation is the standard treatment for PE, but is used in a small proportion of patients with septic PE in general, without risk stratification by severity [1]. In submassive and massive PE, pulmonary endarterectomy has been attempted with success [2]. The alternative treatment options for submassive PE, including fibrinolytics or catheter-assisted pulmonary embolectomy, have conflicting opinions and have not been studied in patients with septic PE. Case reports for septic PE causing chronic thromboembolic pulmonary hypertension have used pulmonary endarterectomy with mixed results [3].

CONCLUSIONS: In our opinion, pulmonary endarterectomy can be considered in the rare patient who presents with submassive septic PE.

Reference #1: Goswami, U., et al., Associations and outcomes of septic pulmonary embolism. Open Respir Med J, 2014. 8: p. 28-33.

Reference #2: Neely, R.C., et al., Surgical Embolectomy for Acute Massive and Submassive Pulmonary Embolism in a Series of 115 Patients. Ann Thorac Surg, 2015. 100(4): p. 1245-51; discussion 1251-2.

Reference #3: Crosland, W., et al., Pulmonary endarterectomy for pulmonary hypertension from septic emboli. Ann Thorac Surg, 2015. 99(5): p. 1814-6.

DISCLOSURE: The following authors have nothing to disclose: Benjamin Shieh, Sean Gilman

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