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

A Case of Acute Pulmonary Embolism With Right Atrial Thrombus Treated With Systemic Thrombolytic Therapy After Surgery FREE TO VIEW

Yera Patel, MD; Apurwa Karki, MD; Jagruti Patel, MD; Samir Sarkar, MD; Ahmed Mahmood, MD
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Jamaica Hospital Medical Center, Jamaica, NY

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

Chest. 2016;150(4_S):1225A. doi:10.1016/j.chest.2016.08.1334
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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: Systemic thrombolytic therapy (STT) has shown mortality benefit in treating submassive pulmonary embolism (PE), however, limited data exists on appropriate use due to risks. We are presenting a case of uncomplicated, complete resolution of right atrial thrombus associated with submassive PE after treatment with systemic tissue type plasminogen activator (tPA).

CASE PRESENTATION: A 38 year-old female with no significant past medical history presented after a syncopal episode followed by dyspnea, chest pain, and dizziness. She had been immobile due to open reduction and internal fixation for right fibular fracture 4 weeks prior to presentation followed by repair of left ankle ligament 3 weeks later due to fall. Patient denied oral contraceptive use or smoking. Patient was hypotensive (76/55mmHg), tachycardic (118beats/min) with oxygen saturation of 97% on room air. Physical examination was remarkable for obesity, loud S2, right lower extremity dressing, and left lower extremity cast. Patient was admitted to medical ICU for close monitoring. Hypotension resolved with intravenous fluids. Blood work was significant for elevated D-dimer (21641ng/ml), pro-BNP (1880pg/mL), and troponin-I (0.225ng/ml). Arterial blood gas analysis failed to reveal any abnormality. Electrocardiogram showed sinus tachycardia with evidence of right ventricular (RV) strain. CT pulmonary angiogram and lower extremity DVT study revealed diffuse bilateral pulmonary emboli (Image 1), and right sided DVT respectively; enoxaparin was started. Transthoracic echocardiogram (TTE) revealed RV dilation and pressure overload, pulmonary artery (PA) pressure of 50mmHg and a large, mobile right atrial (RA) thrombus originating from the deep veins and attached to the tricuspid valve (Image 2). Due to extensive RV thrombus, RV dilation and tachycardia, STT with 100mg of tPA was initiated followed by intravenous heparin without any significant complications. TTE post-thrombolytic therapy showed no evidence of thrombus with marked improvement in PA systolic pressure. Tachycardia improved and patient was discharged home on warfarin.

DISCUSSION: Although guidelines using evidence-based medicine exist, optimal use of STT is debatable in treating submassive PE with RA thrombus post-operatively. Recent major surgery is a relative contraindication to STT. (1) Clots are rapidly dissolved by STT, reducing mortality, but may be associated with major risk of bleeding.

CONCLUSIONS: Our patient with submassive PE with extensive RA thrombus after recent major surgery was successfully treated with STT without major adverse events.

Reference #1: Teleb, M., et al. (2016). Potential role of systemic thrombolysis in acute submassive intermediate risk pulmonary embolism: Review and future perspectives. Therapeutic Advances in Cardiovascular Disease.

DISCLOSURE: The following authors have nothing to disclose: Yera Patel, Apurwa Karki, Jagruti Patel, Samir Sarkar, Ahmed Mahmood

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