Case Report
An 81-year-old woman was admitted to the hospital with progressive
dyspnea and syncope. Two days before the present admission, she had
shortness of breath and a dry cough, and she presented at the emergency
room for further evaluation. She also reported left lower extremity pain
and swelling. On examination, she was in respiratory distress, with
tachypnea (27 breaths/min), blood pressure of 85/56 mmHg, tachycardia
(138 beats/min), and body temperature measuring 36.8°C. Arterial blood
gas analysis under oxygen 2 L/min revealed pH of 7.286; pO2, 66 mmHg;
pCO2, 37 mmHg, and bicarbonate 20.3 mmol/L. Laboratory results included
a D-dimer level of 9.488 μg/mL and an elevated high sensitive troponin I
level of 247.10 ng/mL. Her electrocardiogram showed evidence of a right
bundle branch block, sinus tachycardia, and nonspecific ST-T
abnormality. Chest X-ray did not show any remarkable findings. However,
transthoracic echocardiography showed (TTE) showed a massive right
ventricular and mobile right atrial thrombus and also right sided
enlargement and flattening of the interventricular septum (Figure 1A,
B). Systolic pulmonary artery pressure was calculated as 65 mmHg.
Subsequent chest computed tomography scan disclosed a pulmonary
thromboembolism in both pulmonary arteries (Figure 2A). Under the
diagnosis of an intracardiac mass and suspicious thrombus formation in
the right atrium with acute PE, the patient was admitted to the cardiac
intensive care unit for further treatment.
The patient was immediately administered continuous, high-dose
intravenous heparin for anticoagulation and she was placed on
intravenous inotropes. Cardiothoracic surgeons were consulted regarding
open pulmonary embolectomy. The risks and benefits of both pulmonary
embolectomy and catheter directed thrombolysis (CDT) were extensively
discussed with the patient and her family. Because the patient’s age
made her a high-risk surgical candidate, the decision was made to
proceed with CDT.
After informed consent was obtained, the patient was brought to the
cardiac catheterization laboratory. A right heart catheterization was
performed using a 6 Fr sheath placed in the right common femoral vein
(CFV). Pulmonary angiogram was performed and it showed a subtotal
occlusion in the right main pulmonary artery (PA) and occlusive thrombus
in the left PA branches. The EKOS catheter (30 cm) was then placed from
the junction of the inferior vena cava into the right main PA extending
into the thrombus (Figure 2B). Another EKOS catheter was then implanted
from a second venous sheath placed in the left CFV into the left PA.
A total of 2 mg Actilyse (Alteplase, Boehringer Ingelheim GmbH&-Co,
Ingelheim, Germany) bolus were administered from catheters then 1mg/h
tPA infusion was started for each lung for a total of 18 hours. (total
of 38 mg tPA for both lungs). A total of 1000 units of heparin/h was
infused in each venous sheath for the duration of tPA infusion.
Following 18 hours of tPA infusion, she was feeling quite better with
her heart rate 95 beats/min and systolic blood pressure 125 mmHg. Her
respiratory rate was 17/min, and oxygen saturation was 96%. PA pressure
decreased to 45 mmHg and a progressive decrease in the size of thrombus
was detected in serial echocardiographic examinations. The
echocardiographic examination also showed that the thrombus in the right
ventricular apex and the mobile thrombus in the right atrium had totally
disappeared (Figure. 3A, B).
Forty-eight hours after the procedure, the right side of the heart had
become normal in size, and pulmonary systolic pressure had decreased to
30 mmHg and interventricular septal motion significantly improved.
Within 2 days, computed tomography angiography was repeated. The
intracardiac thrombus and massive PE had both completely resolved
(Figure 2C). The patient was discharged from the hospital 5 days after
initial presentation with instructions to take oral anticoagulants. At
her 3-month follow-up examination, she remained asymptomatic.