Description of Case
A 59-year-old male with a history of hypertension presented with
dyspnea. Vital signs were blood pressure of 159/105 mmHg, pulse 89
beats/min and pulse oximetry of 99% on room air. Physical examination
was unremarkable. Electrocardiogram showed S1Q3T3 pattern (Figure 1).
Chest x-ray was notable for prominent pulmonary arteries (Figure 2).
Laboratory studies revealed elevated NT pro-BNP 2737 pg/Ml, high
sensitivity troponin 86 ng/L, D-dimer 55.45 mg/L, and platelet count
193,000/uL.
Chest computed tomography angiography (CTA) showed large central
bilateral PE (Figure 3). Indications of pulmonary hypertension included
enlargement of the main pulmonary artery (PA) and narrowing of the left
ventricle compared to the right related to heart strain. Venous Doppler
of the lower extremities demonstrated occlusive deep venous thrombosis
(DVT) of left popliteal vein. Transthoracic echocardiogram (TTE)
revealed left ventricular ejection fraction 60% without evidence of
right ventricle (RV) strain.
On hospital day (HD) 2, TTE showed RV systolic pressure (RVSP) of 28
mmHg (Figure 4). Patient clinical status worsened increased oxygen
requirement. Given a significant decrease in platelet count to
62,000/uL, CD thrombolysis was postponed, and an IVC catheter was
placed. Unfractionated heparin was discontinued and argatroban was
initiated for suspected HIT, which was later confirmed with optical
density of 1.011.
On HD 12, platelet count recovered (169,000/uL). Improvement of clot
burden in the left PA but increasing in the right PA with bilateral
pulmonary infarct was seen on repeat chest CT (Figure 5). TTE showed
RVSP of 59 mmHg. Two days following a successful CD thrombectomy and
thrombolysis, he reported feeling less dyspneic. Cardiothoracic surgery
was consulted due to incomplete lysis of right sided PE and recommended
transfer to tertiary center. Chest CTA had shown reduction of the clot
burden by 30%. Final TTE demonstrated RVSP 30 mmHg. Due to sustained
clinical improvement, surgical thrombectomy referral was made on an
outpatient basis and he was discharged on oral anticoagulation.