Pre-operative Course:
A 48 year old male with history of morbid obesity (BMI: 44 kg/m2), C4-C5
laminectomy and partial thyroidectomy one month prior presented to his
local emergency room with new dyspnea on exertion ongoing for two days
followed by a syncopal episode. He had no family history of clotting
disorders and denied alcohol or tobacco use. On presentation he was
normotensive, tachycardic and hypoxic requiring supplemental oxygen.
Pulmonary Embolism (PE) protocol- Computed Tomography (CT) demonstrated
a saddle pulmonary embolus extending into bilateral main pulmonary
arteries and into segmental and subsegmental pulmonary artery branches
bilaterally. Additionally, evidence of right ventricle strain was noted
with right ventricular size larger than left ventricle in diastolic
phase (Image 1). The patient was heparinized and transferred to our
institution. Upon arrival, he was persistently tachycardic and hypoxic.
Laboratory evaluation was notable for an elevated B-type natriuretic
peptide (BNP) of 620 ng/L. Transthoracic echocardiogram revealed
severely enlarged and poorly contractile right ventricle. Left
ventricular contractility and valvular assessment was grossly normal.
Bilateral lower extremities venous duplex ultrasound revealed a left
common femoral deep venous thrombosis. Based on his extensive clot
burden, evidence of acute right heart failure, pulmonary embolectomy was
advised, and the patient proceeded to the operating room urgently for
MIPE.