Surgical Pulmonary Embolectomy.

Abstract

A 66-year-old man with a recent prosthetic knee infection, status post–prosthesis removal, was admitted with recurrent septic arthritis. On his seventh hospital day, as he was signing his discharge paperwork, he developed acute respiratory distress. On physical examination, he was tachycardic to 118 beats/min, relatively hypotensive from 144/78 mm Hg earlier in the day to 94/54 mm Hg, and hypoxemic, with an oxygen saturation of 94% on a 100% nonrebreather facemask. The ECG showed sinus tachycardia. An urgent contrast-enhanced chest computed tomogram (CT) demonstrated large saddle pulmonary embolism (PE) and severe right ventricular (RV) enlargement, with an RV diameter-to-left ventricular (LV) diameter ratio of 1.8 (Figure 1). The patient was administered a bolus of intravenous unfractionated heparin followed by a continuous infusion. An urgent bedside transthoracic echocardiogram showed severe RV dilation, moderate-to-severe pulmonary hypertension, and RV pressure overload as suggested by systolic deviation of the interventricular septum toward the LV (Figure 2). The Vascular Medicine and Cardiac Surgery services were consulted for consideration of advanced therapies. Because of concern for major bleeding associated with fibrinolytic therapy in the setting of recent major surgery, surgical pulmonary embolectomy was recommended. Figure 1. Contrast-enhanced chest computed tomogram (CT) demonstrating acute pulmonary embolism (PE) in a 66-year-old man who developed sudden dyspnea, severe hypoxemia, and relative hypotension. Coronal views demonstrating a large, dense filling defect straddling the bifurcation of the main pulmonary artery consistent with saddle PE ( A ) and extending into the right and left main pulmonary arteries (arrows, B ). Axial view demonstrating a right ventricular (RV) diameter of 4.8 cm in comparison with 2.6 cm for the left ventricle (LV; RV-to-LV diameter ratio of 1.8; normal <0.9) consistent with severe RV enlargement ( C ). Figure 2. Transthoracic echocardiogram, apical 4-chamber view, demonstrating right ventricular (RV) and right atrial (RA) dilation and RV pressure overload with interventricular septal …