Authors Adil Alexander Yunis, MD1, Jeffrey A Fowler, DO1, Phillip Edward Lamberty, MD2. 1Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, 2Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
Case
A 59-year-old male presented to the emergency room with four days of
progressive dyspnea on exertion after a long drive. On the day of
admission, he experienced sudden worsening dyspnea at rest. His past
medical history was significant for hypertension, chronic obstructive
pulmonary disease and tobacco use.
Exam: HR 110, BP 106/61, RR 24, SpO2 100% on 6L NC. Lungs: Clear to auscultation
A. Pulmonary embolism B. Pulmonary embolism with clot in transit C. Pulmonary embolism with clot in transit and impending paradoxical embolism D. Tricuspid Valve endocarditis
Answer
C. Pulmonary embolism with clot in transit and impending paradoxical embolism
Discussion
CTPA filling defects in the right and left main pulmonary arteries
consistent with acute pulmonary embolism. The right ventricle (RV) was
severely dilated with an RV/LV diameter ratio of > 2, a strong
predictor of early death in patients with acute PE (1)
Imaging and laboratory evidence of RV dysfunction with a simplified
PESI score of 3 classified this as a submassive / intermediate-high risk
PE and the patient was referred for catheter-based intervention.
Point of care ultrasound (POCUS) was performed prior to the start of the procedure.
POCUS revealed an 8.7 cm x 1.9 cm mobile echodensity in the RA,
prolapsing into the RV, crossing a patent foramen ovale (PFO) into the
LA, consistent with clot in transit (CIT). POCUS also showed RV
hypokinesis with preserved apical function (McConnell’s sign).
The patient was sent for emergent surgical thrombectomy and PFO
closure given the risk for paradoxical embolism. The CIT was
successfully removed intact (pictured below) as were multiple pulmonary
arterial clots, and he was discharged home 8 days later.
While CTPA remains the method of choice for diagnosing PE, POCUS
provides crucial data for risk stratifying sub-massive PE such as RV
strain and CIT. In retrospect, the patient’s CTPA exhibited evidence of
the CIT with a tubular filling defect in the right heart. In retrospect,
a LA filling defect adjacent to the RA was detected on CT consistent
with clot traversing a PFO.
The prevalence of CIT in the setting of PE is approximately 7-18%,
but with increased use of POCUS this number is likely to rise (2,3). The
diagnosis of CIT has prognostic significance as the overall mortality
rate for PE with CIT has been reported as exceeding 40% (4). Rapid
intervention is warranted, due to the risk for embolization to the
pulmonary arteries and circulatory collapse. Traditional treatment with
surgical embolectomy and systemic thrombolytics demonstrates similar
outcomes in observational studies (5). Based on case reviews, surgery
may be the preferred treatment in the rare event of a CIT traversing a
PFO, allowing for both embolectomy and PFO closure (6)
Routine echocardiography in all PE cases is controversial, but its
use remains advisable for higher risk patients with PE by facilitating
further risk stratification through the assessment of RV function and
detection of CIT (7). The use of POCUS to diagnose our patient’s CIT
crossing a PFO was critical in selecting surgical embolectomy rather
than catheter-based techniques.
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