Massive Pulmonary Embolization
Diagnostic and Therapeutic Images
A 44-year-old man who had undergone 3-vessel coronary artery bypass graft surgery 1 week earlier presented with a 1-day history of dyspnea at rest and near syncope. His physical examination was remarkable for tachycardia (134 bpm) and tachypnea (rate=34). Cardiac and pulmonary examinations were otherwise normal. Chest radiography was unremarkable except for postsurgical cardiac changes. The ECG demonstrated sinus tachycardia and an SI,QIII,TIII pattern (Figure 1), suggestive of pulmonary embolization. Laboratory examination showed a total leukocyte count of 17 500, hemocrit value of 10.8 g, and d-dimer at >40.
Concern for pulmonary embolism prompted therapy with heparin. CT with contrast (Figure 2) revealed a large thrombus in the main pulmonary artery. Systolic blood pressure decreased to ≈100 mm Hg, but because of the patient’s recent surgery, systemic thrombolytic therapy was felt to be contraindicated. A local infusion of tissue-type plasminogen activator was initiated, and catheter extraction of the emboli was attempted without success. Serial pulmonary angiography revealed only minimal clot resolution; however, hemoptysis ensued.
The patient’s respiratory status deteriorated, requiring 100% oxygen and then intubation. Echocardiography demonstrated right ventricular enlargement and dysfunction (Figure 3). On the basis of the presence of hemodynamically compromising pulmonary embolism and right ventricular dysfunction in the setting of ineffective clot lysis, the patient was referred for surgical embolectomy. In the operating room before sternotomy, an inferior vena caval filter was placed. During this procedure, hypotension and bradycardia occurred, and the patient was placed on cardiopulmonary bypass. A large amount of thrombus was subsequently removed from the pulmonary artery (Figure 4). The patient survived without sequelae and is currently doing well without functional compromise.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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