Venous Thromboembolism in Progress

Abstract

A 67-year-old man with a history of inferior infarction was admitted to our hospital because of a near-syncopal episode, sudden dyspnea, and right-sided pleuritic chest pain. On physical examination, the patient appeared in distress with a blood pressure of 79/58 mm Hg and a heart rate of 123 beats/min. The initial electrocardiogram revealed sinus tachycardia; right bundle-branch block; S wave in lead I; Q wave in leads II, III, and aVF; and T-wave inversion in leads V1 to V4 (Figure, A). The patient's left lower extremity was swollen, tender, and slightly warm; Doppler ultrasonography showed a large floating thrombus in the left femoral vein, resembling a turtle (Figure, B and Video 1, in Supporting Online Material, a link to which is provided at the end of this article). A transthoracic echocardiogram revealed moderately right ventricular dilatation, apical hypokinesis, and a highly mobile right atrial thrombus (arrows) prolapsing through the tricuspid valve during systole (Figure, C), early diastole (Figure, D), and end-diastole (Figure, E and Video 2, first part). Chest computed tomography revealed a large thrombus straddling the bifurcation of the main pulmonary artery (“saddle” embolus) (Figure G, arrow), multiple bilateral emboli in the peripheral pulmonary arteries and right upper lobe, and several wedge-shaped parenchymal opacities with a broad pleural base, compatible with pulmonary infarctions (Figure, H and I, arrows) and classically described as Hampton hump when seen on chest radiography. Abdominal computed tomography revealed an extensive thrombosis of the inferior vena cava (Figure J, arrow). Thrombolysis with intravenous alteplase followed by an unfractionated heparin infusion for 24 hours improved the patient's symptoms. The mass in the right atrium was no longer evident on an echocardiogram obtained 5 hours after thrombolysis (Figure, F and Video 2, last part). Mobile right atrial thrombi are uncommon but are probably underdiagnosed in patients with pulmonary embolism. They are detected in about 18% of patients with acute pulmonary embolism1 and are usually associated with hemodynamic instability, which increases the risk of mortality.2