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.