Clinical Case 06—A fatal dance: a case report of a pulmonary embolism with mobile right ventricular thrombus. (21st October 2022)

• Record Type: Journal Article
• Authors: Gonçalves, Carolina Miguel; Carvalho, Mariana; Vazão, Adriana; Fernandes, Sara; Cabral, Margarida; Carvalho, Rita; Martins, Hélia; Saraiva, Fátima; Morais, João
• Is Part Of: Cardiovascular research. Volume 118(2022)Supplement 2
• Publication Date: 2022-10-21
• Subjects: Cardiovascular system -- Diseases -- Periodicals; Cardiovascular system -- Periodicals; 616.1
• DOI: 10.1093/cvr/cvac157.125
• Languages: English
• ISSNs: 0008-6363

Abstract

Abstract: Presentation: We report a case of a 44-year-old woman with past medical history of dyslipidemia under atorvastatin, overweight and depression, that presented to the emergency department with a 1-month history of dyspnea. On physical examination, blood pressure was within normal range, however she was hypoxemic, needing oxygen via nasal cannula, and tachycardic. Pulmonary auscultation revealed basal crackles. Blood workup showed discrete leukocytosis, increased C-reactive protein, mild hypertransaminasemia and increased troponin and NT-proBNP levels. An EKG revealed sinus tachycardia with 123 beats per minute. A D-shaped left ventricle, an enlarged right ventricle and right heart mobile thrombus were observed in a transthoracic echocardiogram. Diagnosis: Scoring 2 points on simplified Wells' Score and with a visible mobile right ventricular thrombus, pulmonary embolism was suspected and further confirmed by computed tomographic pulmonary angiography. Management: In the absence of hemodynamic instability this case fulfils criteria for intermediate-high risk pulmonary embolism. Therefore, anticoagulation with enoxaparin was started under strict electrocardiographic monitoring. Unfortunately, a day later the patient had a sudden cardiac arrest in asystole, with no recuperation after prolonged advanced life support and administration of rescue thrombolysis (alteplase 50mg). Learning points: The real frequency of right ventricular thrombi in the setting of pulmonary embolism is uncertain, however it appears to be rare. According to several observational studies, it is associated with hemodynamic instability at presentation and with worse prognosis. Optimal management remains controversial. Thrombolysis or surgical embolectomy may be considered though further research is needed to establish the most appropriated treatment. Figure 1 Mobile right ventricular thrombus in transthoracic echocardiography—4- chamber view focusing the right ventricle.