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.