Dataset Information

Development of massive pulmonary embolism during echocardiographic imaging: A case report.

ABSTRACT:

Rationale

Pulmonary embolism (PE) is a common diagnostic consideration for patients who present to the emergency department (ED) with chest pain, dyspnea, or both. In addition, PE has a very high mortality in patients who are hemodynamically unstable. An electrocardiography, bedside transthoracic echocardiogram, and computed tomography pulmonary angiogram are usually performed to confirm the diagnosis.

Patient concerns

A 53-year-old man was admitted to the cardiology clinic with complaints of dyspnea, chest pain, and general weakness after walking. He had a history of hypertension and smoking.

Diagnosis

During synchronous recording of echocardiographic images, a large mobile thrombus detached from the right atrium, and first embolized to the right ventricle and then to the main pulmonary artery from the right heart chambers. Soon after, shortness of breath developed which clinically worsened the patient. Transthoracic echocardiogram which demonstrated the thrombus in the pulmonary artery or right heart chambers was suspected of causing acute massive PE.

Interventions

The patient was transferred to Critical Care Unit for monitoring; 100?mg of alteplase was initiated immediately and alleviated the hemodynamic instability within 2?hours of intravenous administration.

Outcomes

To the best of our knowledge, this is the first synchronous echocardiographic recording showing the embolization of a thrombus from the right atrium, first to the right ventricle and then to the main pulmonary artery.

Lessons

Transthoracic echocardiography provides a safe, rapid, and noninvasive diagnostic tool for evaluation of suspected massive PE. Thrombolytic therapy is useful for treating acute massive PE that leads to hemodynamic instability.

SUBMITTER: Guntekin U

PROVIDER: S-EPMC5908560 | biostudies-literature | 2018 Apr

REPOSITORIES: biostudies-literature

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Publications

Development of massive pulmonary embolism during echocardiographic imaging: A case report.

Guntekin Unal U Dogan Umuttan U Goldag Omer Gorkem OG Kandemir Yasemin Behram YB Tosun Veysel V

Medicine 20180401 15

<h4>Rationale</h4>Pulmonary embolism (PE) is a common diagnostic consideration for patients who present to the emergency department (ED) with chest pain, dyspnea, or both. In addition, PE has a very high mortality in patients who are hemodynamically unstable. An electrocardiography, bedside transthoracic echocardiogram, and computed tomography pulmonary angiogram are usually performed to confirm the diagnosis.<h4>Patient concerns</h4>A 53-year-old man was admitted to the cardiology clinic with c ...[more]

PMID: 29642185

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Project description:BackgroundTo our knowledge we report the first case of percutaneous mechanical thrombectomy used for the treatment of massive pulmonary embolism in the United Kingdom. Pulmonary embolism is a common disease process but can be difficult to diagnose. Massive pulmonary embolism presenting with profound hypotension, however, is rare. Both phenomena carry with them significant mortality. Traditionally those patients suffering haemodynamic compromise from pulmonary embolism are treated with intravenous or catheter-directed thrombolysis. When this is contraindicated surgical embolectomy or mechanical techniques via a right heart catheter are alternative options. The former is well established but the latter is less commonly utilised in clinical practice. Our aim is to highlight the effectiveness and relative safety of percutaneous mechanical thrombectomy as a therapeutic tool in massive pulmonary embolism.Case presentationA 70 year-old gentleman presented with a 4-month history of dry cough and general malaise. Clinical examination along with routine chest radiograph confirmed a left pleural effusion which was drained. Computed tomography of the chest, abdomen and pelvis revealed a left renal mass consistent with renal cell carcinoma plus multiple metastatic subpleural nodules. Following planned thoracoscopy and pleural biopsy the patient became acutely dyspnoeic and hypotensive. Relevant investigations including computed tomography pulmonary angiogram confirmed a large saddle embolus extending in to the lobar branches of both left and right pulmonary arteries. There were several relative contraindications to thrombolysis and so the patient proceeded to have percutaneous mechanical thrombectomy with excellent results. The patient made a full recovery from the acute episode and was discharged home on warfarin with a view to planned cyto-reductive nephrectomy.ConclusionWe illustrate here that percutaneous mechanical thrombectomy can be a safe and effective method of treating massive pulmonary embolism when thrombolysis is relatively contraindicated. It may also be of use as an adjuvant therapy in those patients able to receive thrombolysis. In the future further evaluation involving a larger cohort of subjects is necessary to determine whether this treatment is superior to surgical embolectomy when thrombolysis cannot be performed.

Project description:BackgroundPatients with severe COVID-19 pneumonia are hypercoagulable and are at risk for acute pulmonary embolism. Timely diagnosis is imperative for their prognosis and recovery. This case describes an otherwise healthy 55-year-old man with respiratory failure requiring mechanical ventilatory support secondary to COVID-19 pneumonia. Massive acute pulmonary embolism with right heart failure complicated his course.CaseA healthy 55-year-old man presented to our emergency department (ED) with a sore throat, cough, and myalgia. A nasopharyngeal swab was obtained, and he was discharged for home quarantine. His swab turned positive for SARS-CoV-2 infection on real-time reverse transcriptase-polymerase chain reaction assay (RT-PCR) on day 2 of his ED visit. A week later, he represented with worsening shortness of breath, requiring intubation for hypoxic respiratory failure due to COVID-19 pneumonia. Initially, he was easy to oxygenate, had no hemodynamic compromise, and was afebrile. On day 3, he became febrile and developed significant hemodynamic instability requiring maximum vasopressor support and oxygenation difficulty. His ECG revealed sinus tachycardia with S1Q3T3 pattern. On bedside TTE, there was evidence of right heart strain and elevated pulmonary artery systolic pressure of 45 mmHg. All data was indicative of a massive APE as the etiology for his hemodynamic collapse. A decision was made to forgo computed tomography pulmonary angiography (CTPA), given his clinical instability, and systemic thrombolytic therapy was administered. Within the next 12-24 hours, his hemodynamic status significantly improved.ConclusionsThis case highlights the importance of considering massive APE in COVID-19 patients as a cause of the sudden and rapid hemodynamic decline. Furthermore, timely diagnosis can be made to aid in appropriate management with the help of bedside TTE and ECG in cases where CTPA is not feasible secondary to the patient's hemodynamic instability.

Dataset Information

Development of massive pulmonary embolism during echocardiographic imaging: A case report.

Rationale

Patient concerns

Diagnosis

Interventions

Outcomes

Lessons

Publications

Development of massive pulmonary embolism during echocardiographic imaging: A case report.

Similar Datasets

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