LARGE SADDLE PULMONARY EMBOLISM WITH RIGHT VENTRICULAR DYSFUNCTION IN AN ASYMPTOMATIC PATIENT

Abstract

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Definition of saddle pulmonary embolism (PE) is a visible thromboembolus straddling the bifurcation of the main pulmonary artery trunk. Saddle pulmonary embolism occurs in 5.2% cases in all patients with pulmonary embolism (1). We report an atypical case of an asymptomatic and hemodynamically stable patient with a saddle PE and right ventricular (RV) strain. CASE PRESENTATION: A 65-year-old man with history of schizophrenia, polysubstance abuse on methadone, hepatic fibrosis, lung nodules reported 1 hour of transient chest pain and SOB two days before ER visit. On admission he did not have any symptoms. He denied risk factors for deep venous thrombosis. All vital signs were normal. Clinical examination revealed attenuated pulmonic component of the second heart sound. Electrocardiogram (EKG) revealed new biphasic t-waves in anterior leads. Labs were significant for troponin ultra 0.43 ng/ml. He was initially admitted to CCU for acute myocardial infarction without ST segment elevation in the settings of elevated troponin and new EKG changes of biphasic T waves in anterior leads. Repeated EKG - right axis deviation. Echocardiogram (ECHO- normal left ventricle, RV function was severely reduced and size severely enlarged, abnormal septal motion during diastole and systole consistent with volume and pressure overload and pulmonary pressure of 43 mmHg. CT pulmonary angiography (CTPA) was positive for saddle PE extending into all 5 lobes of the lungs (figure 1). Venous scan of lower extremities revealed deep venous thrombosis of the right popliteal vein. Treatment for PE was initiated with therapeutic dose of anticoagulation therapy. He remained hemodynamically stable and asymptomatic throughout the course and his hospital stay was uneventful and he was discharged on therapeutic dose Apixaban. DISCUSSION: Risk assessment for acute PE includes classification according to hemodynamic instability with patients presenting with hemodynamic instability being high risk for 30 days mortality and requiring reperfusion treatment (systemic thrombolysis or pulmonary embolectomy). Patient with hemodynamic stability but with RV strain on ECHO or CTPA have intermediate high risk and can be treated with parenteral or oral AC and rescue reperfusion if deterioration happens (2). CONCLUSIONS: Conclusion: Patient with RV strain and large saddle PE can remained hemodynamically stable and can adequately be managed with AC therapy. REFERENCE #1: Musani MH. Asymptomatic saddle pulmonary embolism: case report and literature review. Clin Appl Thromb Hemost. 2011 Aug;17(4):337-9. doi: 10.1177/1076029610363588. Epub 2010 Mar 22. PMID: 20308228. REFERENCE #2: Stavros V. Konstantinides, Guy Meyer, Cecilia Becattini, Héctor Bueno, Geert-Jan Geersing, Veli-Pekka Harjola, Menno V. Huisman, Marc Humbert, Catriona Sian Jennings, David Jiménez, Nils Kucher, Irene Marthe Lang, Mareike Lankeit, Roberto Lorusso, Lucia Mazzolai, Nicolas Meneveau, Fionnuala Ní Áinle, Paolo Prandoni, Piotr Pruszczyk, Marc Righini, Adam Torbicki, Eric Van Belle, José Luis Zamorano, 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS), European Respiratory Journal 2019; DOI: 10.1183/13993003.01647-2019 DISCLOSURES: no disclosure on file for Moses Bachan; no disclosure on file for Zinobia Khan; No relevant relationships by Mirjana Petrovic Elbaz, source=Web Response No relevant relationships by Robert Siegel, source=Web Response No relevant relationships by Swarnalatha Uday sumathy, source=Web Response