Presentation Of Massive Pulmonary Embolism Research Articles

Surgical Management of Massive Pulmonary Embolism Presenting with Cardiopulmonary Arrest: How Far Is Too Far?

The incidence of diagnosed massive pulmonary embolism presenting to the Emergency Department is between 3% and 4.5% and it is associated with high mortality if not intervened timely. Cardiopulmonary arrest in this subset of patients carries a very poor prognosis, and various treating pathways have been applied with modest rate of success. Systemic thrombolysis is an established first line of treatment, but surgeons are often involved in the decision-making because of the improving surgical pulmonary embolectomy outcomes.

Massive Pulmonary Embolism Presenting as Obstructive Shock in a Nigerian Woman: A Case Report

Massive Pulmonary Embolism Presenting as Obstructive Shock in a Nigerian Woman: A Case Report

BEFORE OUR EYES: A CLOT-IN-TRANSIT LEADING TO CARDIAC ARREST AND RETURN OF SPONTANEOUS CIRCULATION WITH SYSTEMIC THROMBOLYSIS

BEFORE OUR EYES: A CLOT-IN-TRANSIT LEADING TO CARDIAC ARREST AND RETURN OF SPONTANEOUS CIRCULATION WITH SYSTEMIC THROMBOLYSIS

Massive pulmonary embolism presenting with hemoptysis and S1Q3T3 ECG findings

BackgroundVenous thromboembolism clinically presenting with a deep vein thrombosis or pulmonary embolism is among the most commonly seen cardiovascular syndromes. The aim of this case presentation is to emphasise the typical electrocardiographic findings that are detected with massive pulmonary embolism along with the electrocardiographic S1Q3 and S1Q3T3 accompanied by T negativity at the D3 derivation based on prevalent T negativity.Case presentationWe present the case of an adult male who presented with a massive pulmonary embolism that was associated with tachycardia, haemoptysis and typical S1Q3T3 electrocardiographic findings. Tomographic findings showed filling defects in the two main pulmonary artery lumens, which were found to be compatible with a massive embolism. Intravenous heparin was injected (5000 IU), and low molecule weight heparin (LMWH) treatment was initiated. After two days of observation and treatment in the coronary intensive care unit, the patient was discharged for outpatient care.DiscussionMassive pulmonary embolism is an urgent life-threatening clinical situation that is frequently confused with acute ST elevation myocardial infarction. The definitive diagnosis of massive pulmonary embolism was made with a computed tomography pulmonary angiogram. Electrocardiographic findings and hypoxic hypercarbia in the blood gas analysis are typical. Early diagnosis with laboratory and imaging investigations is vital in the treatment and prognosis of pulmonary embolism.ConclusionsVentricular overload signs accompanied by ST segment elevation in electrocardiography and S1Q3 and prevalent T negativity are crucial features in terms of distinguishing between pulmonary embolism and myocardial infarction and selecting effective treatments for patients admitted to the emergency department.

Massive pulmonary embolism presenting with acute hemiparesis and aphasia: a case report of paradoxical embolism documented with transthoracic echocardiography

Massive pulmonary embolism presenting with acute hemiparesis and aphasia: a case report of paradoxical embolism documented with transthoracic echocardiography

Leg massage during pregnancy with unrecognized deep vein thrombosis could be life threatening: a case report

BackgroundTraditional massage seems to be safe but not entirely risk free, though serious adverse events are very rare. This report is aimed at illustrating a rare but fatal presentation of massive pulmonary embolism caused by leg massage and also to encourage both massage providers and pregnant women to be aware of undetected or subtle deep vein thrombosis, which could be a life threatening condition as a consequence of leg massage.Case presentationA 25-year-old primigravid Thai woman underwent massage at a traditional massage shop at 25th week of gestation. Shortly after leg and foot massage, she had a sudden onset of dyspnea, followed by consciousness alteration, brief spastic-like convulsion, became unconscious and suffered a cardiac arrest. Basic life support (BLS) at the event scene as well as during transfer and advanced cardiovascular life support (ACLS) at the hospital were provided, resulting in successful resuscitation but persistent coma. Bedside echocardiography showed poor contractility of the dilated right ventricle, and pulmonary embolism was suspected. CT angiography (CTA) revealed multiple concentric intraluminal filling defects within the right and left pulmonary arteries, indicating massive pulmonary embolism. The fetus died in utero and spontaneous labor and vaginal delivery occurred.ConclusionLeg massage in patients with deep vein thrombosis can dislodge thrombi, leading to life threatening pulmonary embolism, and should be contraindicated. Since pregnant women are at a higher risk of undetected or subtle thromboembolism, traditional massage in pregnant women should be contraindicated unless they are proven to have no such risk.

It's a ST-Elevation Myocardial Infarction (STEMI), or Is It? Massive Pulmonary Embolism Presenting as STEMI

It's a ST-Elevation Myocardial Infarction (STEMI), or Is It? Massive Pulmonary Embolism Presenting as STEMI

Catheter directed thrombolytic therapy and percutaneous thrombectomy

Abstract 40% of DVTs occur in the femoral and iliac veins and have a high risk of pulmonary thromboembolism and Post Thrombotic Syndrome (PTS), which can be avoided by timely interventional management. Catheter Directed Thrombolytic Therapy (CDTT) and Pharmacomechanical Catheter-Directed Thrombolysis (PCDT), (combination of CDTT with percutaneous mechanical thrombectomy) techniques enhance the efficiency and rate of thrombus removal. It also uncovers the May Thurner syndrome in many cases. Massive Pulmonary Embolism (PE) is associated with high morbidity and mortality due to thrombotic occlusion of main pulmonary artery and/or both major pulmonary arteries leading to severe hypoxemia, pulmonary artery hypertension and cardiogenic shock. Till now, open surgical pulmonary endarterectomy was the only option for prompt restoration of flow in major pulmonary arteries but carried a high mortality in hemodynamically unstable patients. Catheter based pulmonary thromboaspiration and intrapulmonary thrombolysis can be used. We present our experience in 45 consecutive patients of massive PE presenting with cardiogenic shock.

Retrograde Pulmonary Embolectomy for Acute Pulmonary Embolism: A Simplified Technique

Surgical embolectomy in acute pulmonary embolism is usually reserved for patients with massive pulmonary embolism presenting with cardiogenic shock, or for whom thrombolysis is absolutely contraindicated or has failed. Incomplete removal of thrombotic material lodged in the distal pulmonary arterial bed is considered an important cause of persistent pulmonary hypertension. Retrograde pulmonary embolectomy is an adjunct to conventional pulmonary embolectomy, resulting in more complete embolectomy, specifically of material lodged in the distal pulmonary arterial bed. We describe our simplified technique of retrograde pulmonary embolectomy as a safe adjunct to conventional pulmonary embolectomy.

Emergent echocardiography and extracorporeal membrane oxygenation: Lifesaving in massive pulmonary embolism

Massive pulmonary embolism is a life-threatening emergency that results in circulatory failure. The main challenges in management are early diagnosis and maintenance of hemodynamic stability. We present a case of a 63-year-old male who was in cardiac arrest. After resuscitation, massive pulmonary embolism was diagnosed with the help of bedside echocardiography and extracorporeal membrane oxygenation (ECMO). We were able to maintain hemodynamic stability and improve hypoxia until the patient underwent embolectomy. This case demonstrates a common presentation of massive pulmonary embolism highlighting the main challenges in its management and the role of echocardiography and ECMO in improving outcomes in such scenarios.

A Case of Massive Pulmonary Embolism Due to Diabetic Ketoacidosis and Hyperhomocysteinemia

A 57-year-old woman with no prior history was admitted to our emergency department with complaints of chest pain, dyspnea, xerostomia, syncope, and cyanosis on her lips and feet. On her physical examination, cyanosis, tachypnea, hypotension and sinus tachycardia were revealed. On the spiral computed tomography of the thorax of the patient with diabetic ketoacidosis, thrombus was detected in the left and right main pulmonary artery and segmental branches of the right pulmonary artery. The fibrinolytic treatment was initiated in the emergency department for the patient with hemodynamic shock due to the diagnosis of acute massive pulmonary embolism. Etiological examinations revealed B12 deficiency and hyperhomocysteinemia. This case, with the presentation of massive pulmonary embolism, resulted from the synergistic effect of hyperhomocysteinemia associated with B12 deficiency; hypovolemia caused by diabetic ketoacidosis was reported owing to its rareness.

Acute Surgical Abdomen: An Unusual Presentation of Pulmonary Embolus.

Background. Pulmonary embolism is a common and potentially lethal condition. Most patients who die from massive pulmonary embolism do so within the first few hours of the event. The clinical manifestations of pulmonary embolism are nonspecific, which makes the diagnosis difficult. Case Report. We present a case of massive pulmonary embolism presenting as an acute surgical abdomen that underwent exploratory laparotomy and made a complete recovery. Why should an emergency physician be aware of this? Emergency department physicians should be aware that massive pulmonary embolism could present as an acute surgical abdomen in young healthy individuals.

Urgent bedside echocardiography in diagnosis of acute massive pulmonary embolism presenting with cardiogenic shock – case report

Cardiologia CROATICA We are presenting the case of a 51-year-old man who has been admitted at our clinic with dyspnea, cardiogenic shock and severe pain and swelling of the left leg. At the admission he was cyanotic, severely hypotensive, with tachypnea, an oxygen saturation of 70%. An acute massive pulmonary embolism was suspected, and an emergency bedside transthoracic echocardiogram was performed. Bedside echocardiography showed significantly enlarged right ventricle (46 mm tricuspid annular size), hypokinesia of the free right ventricular wall and increased pulmonary artery size (34 mm), with signs of RV overload. There was large mobile thrombus with dimensions (34x37 mm) prolabing from right ventricle to the right atrium. Severe tricuspid regurgitation, with dilated right atrium and dilated vena cava inferior — 24 mm were found. Indirect estimation of the pulmonary hypertension with the value of the maximal velocity of the tricuspid regurgitation showed increased pulmonary pressure (estimated systolic pulmonary atrial pressure — SPAP was 59 mmHg). Color Duplex sonography of lower extremities was also performed at the bed site with the finding of non compressible left common femoral vein, which was consistent with the deep vein thrombosis. D-dimmers were significantly increased (>4.500 nq/l). Multislice computed tomography performed next day confirmed central filling defect of the left pulmonary artery consistent with acute thrombus. Based on the patient’s clinical condition and the echocardiographic findings, he has been treated with fibrinolysis therapy with alteplase. Control echocardiography performed three days after fibrinolytic therapy showed decrease in SPAP pressure from 59 mmHg to 40 mmHg, moderate tricuspid regurgitation, normal right ventricular size and function. The patient had excellent clinical recovery and was discharged from the hospital after 20 days. This case confirms the role of urgent bedside echocardiography in fast diagnosis of acute pulmonary embolism, which leads to proper management and favorable patient outcome.

Mechanical breakdown and thrombolysis in subacute massive pulmonary embolism: A prospective trial

To assess role of combined modality of mechanical fragmentation and intralesional thrombolysis in patients with massive pulmonary embolism presenting subacutely. Eight of 70 patients presenting in tertiary care centre of North India with massive pulmonary embolism within 4 years had subacute presentation (symptom onset more than 2 wk). These patients were subjected to pulmonary angiography with intention to treat basis via mechanical breakdown and intra lesional thrombolysis. Mechanical breakdown of embolus was accomplished with 5-F multipurpose catheter to re-establish flow, followed by intralesional infusion of urokinase (4400 IU/kg over 10 min followed by 4400 IU/kg per hour over 24 h). Eight patients, mean age 47.77 ± 12.20 years presented with subacute pulmonary embolism (mean duration of symptoms 2.4 wk). At presentation, mean heart rate, shock index, miller score and mean pulmonary pressures were 101.5 ± 15.2/min, 0.995 ± 0.156, 23.87 ± 3.76 and 37.62 ± 6.67 mmHg which reduced to 91.5 ± 12.2/min (P = 0.0325), 0.789 ± 0.139 (P = 0.0019), 5.87 ± 1.73 (P = 0.0000004) and 27.75 ± 8.66 mmHg (P = 0.0003) post procedurally. Mean BP improved from 80.00 ± 3.09 mmHg to 90.58 ± 9.13 mmHg (P = 0.0100) post procedurally. Minor complications in the form of local hematoma-minor hematoma in 1 (12.5%), and pseudoaneurysm (due to femoral artery puncture) in 1 (12.5 %) patient were seen. At 30 d and 6 mo follow up survival rate was 100% and all the patients were asymptomatic and in New York Heart Association class 1. Combined modality of mechanical fragmentation and intralesional thrombolysis appears to be a promising alternative to high risk surgical procedures in patients with subacute massive pulmonary embolism.

Giant Inverted T waves in the emergency department: case report and review of differential diagnoses

Inverted T waves are frequently seen in electrocardiograms (ECGs) and may represent a myriad of pathologies or nonspecific change. However, deep (giant) inverted T waves are only seen in a few clinical conditions. Presence of giant T waves should generally prompt investigations for apical (Yamaguchi) variant of hypertrophic cardiomyopathy, raised intracranial pressure, severe myocardial ischemia, posttachycardia syndrome, and others. This report describes an unusual case of moderate but not massive pulmonary embolism presenting with an ECG finding of giant inverted T waves. A review of the common conditions associated with such an ECG is also presented.

An unusual presentation of massive pulmonary embolism mimicking septal acute myocardial infarction treated with tenecteplase

A 31-year-old man (175 cm, 82 kg) was referred to the emergency department 2 h after the sudden onset of acute dyspnea. Immediate ECG showed sinus tachycardia with ST elevations from V1 through V2 and a diagnosis of septal acute myocardial infarction was made. ECG on admission to the cardiology department showed the same results plus the S1-Q3-T3 pattern. Echocardiogram revealed a normally contracting left ventricle, a distended right ventricle with free wall hypokinesia and displacement of the interventricular septum towards the left ventricle. Thrombolytic therapy with tenecteplase 8000 IU and heparin 5000 IU was administered 5-10 min after hospitalisation and the patient was haemodynamically stable 30 min later. Echocardiogram performed 12 h after thrombolysis showed a normal left ventricle and a less distended right ventricle. Lung spiral computed tomography (CT) and lower abdominal CT on the fourth day showed large emboli in the inferior pulmonary arteries of the right and left lung. Rarely, massive pulmonary embolism may mimic anteroseptal acute myocardial infarction on ECG and this case demonstrates the utility of echocardiography for a differential diagnosis, as well as the efficacy of tenecteplase for thrombolytic therapy.

Percutaneous mechanical thrombectomy for the treatment of acute massive pulmonary embolism: case report

BackgroundTo our knowledge we report the first case of percutaneous mechanical thrombectomy used for the treatment of massive pulmonary embolism in the United Kingdom. Pulmonary embolism is a common disease process but can be difficult to diagnose. Massive pulmonary embolism presenting with profound hypotension, however, is rare. Both phenomena carry with them significant mortality. Traditionally those patients suffering haemodynamic compromise from pulmonary embolism are treated with intravenous or catheter-directed thrombolysis. When this is contraindicated surgical embolectomy or mechanical techniques via a right heart catheter are alternative options. The former is well established but the latter is less commonly utilised in clinical practice. Our aim is to highlight the effectiveness and relative safety of percutaneous mechanical thrombectomy as a therapeutic tool in massive pulmonary embolism.Case presentationA 70 year-old gentleman presented with a 4-month history of dry cough and general malaise. Clinical examination along with routine chest radiograph confirmed a left pleural effusion which was drained. Computed tomography of the chest, abdomen and pelvis revealed a left renal mass consistent with renal cell carcinoma plus multiple metastatic subpleural nodules. Following planned thoracoscopy and pleural biopsy the patient became acutely dyspnoeic and hypotensive. Relevant investigations including computed tomography pulmonary angiogram confirmed a large saddle embolus extending in to the lobar branches of both left and right pulmonary arteries. There were several relative contraindications to thrombolysis and so the patient proceeded to have percutaneous mechanical thrombectomy with excellent results. The patient made a full recovery from the acute episode and was discharged home on warfarin with a view to planned cyto-reductive nephrectomy.ConclusionWe illustrate here that percutaneous mechanical thrombectomy can be a safe and effective method of treating massive pulmonary embolism when thrombolysis is relatively contraindicated. It may also be of use as an adjuvant therapy in those patients able to receive thrombolysis. In the future further evaluation involving a larger cohort of subjects is necessary to determine whether this treatment is superior to surgical embolectomy when thrombolysis cannot be performed.

Massive Pulmonary Embolism Presenting as Ascites.

Massive Pulmonary Embolism Presenting as Ascites.

Should thrombolytic therapy be used in patients with pulmonary embolism?

More than thirty years have passed since streptokinase was first shown to dissolve pulmonary arterial thrombi and normalize pulmonary artery pressure in patients with acute pulmonary embolism (PE). Following the initial observations, a number of controlled clinical trials confirmed that treatment with streptokinase, urokinase or alteplase recombinant tissue plasminogen activator is superior to heparin alone in improving angiographic and hemodynamic parameters in these patients. At present, there is consensus that patients with massive PE presenting with overt right ventricular failure (clinical instability and cardiogenic shock) should promptly be treated with thrombolytic agents, since they are at a particularly high risk for death or life-threatening complications during the acute phase. At the other end of the clinical spectrum, thrombolysis for PE is not indicated in the absence of right ventricular dysfunction. In fact, the prognosis of patients with small pulmonary emboli (not affecting pulmonary artery pressure and right ventricular afterload), is excellent and, as a result, the bleeding risks of thrombolysis may outweigh the potential benefits of this treatment. Currently, the thrombolysis debate focuses on patients with submassive PE, i.e. those who present with signs of subclinical, impending right heart failure. Recently, a number of clinical studies demonstrated that these patients are also at risk for an adverse clinical outcome. Besides the established prognostic value of echocardiography, evidence is now accumulating that cardiac troponins and, possibly, pro-brain natriuretic peptide levels also may permit an early, reliable risk stratification of patients with PE and particularly help identify submassive PE in the presence of apparent clinical stability. Recently, the Management Strategies and Prognosis of Pulmonary Embolism-3 trial examined the effects of thrombolysis on the prognosis of patients with acute submassive PE. The study patients were randomly assigned to receive alteplase (100 mg over 2 hours) or placebo with concomitant heparin anticoagulation. Although in-hospital mortality was low in both the alteplase and the heparin-only group, this study showed for the first time that early treatment with alteplase can improve the clinical course of patients with acute submassive PE, and particularly reduce the need for emergency escalation of treatment. Importantly, no fatal or cerebral bleeding episodes were observed in the alteplase group. This fact indicates that use of thrombolysis in PE can be safe in patients who have no contraindications to this type of treatment. Based on these data, the indications for thrombolysis can be extended to include patients presenting with submassive PE.

Massive pulmonary embolism presenting as complete unilateral absence of lung perfusion on pulmonary scintigraphy: correlative imaging with angiography and computed tomography.

The most important application of pulmonary scintigraphy is in the evaluation of patients with possible pulmonary embolism. Classically, the perfusion defects of pulmonary embolism are wedge shaped, pleural based, and tend to affect both lungs randomly in a segmental or subsegmental distribution. The authors describe a patient with rare scintigraphic findings of complete unilateral absence of lung perfusion with normal lung ventilation caused by massive pulmonary embolism associated with activated protein C resistance. Correlative imaging with angiography and computed tomography (CT) is presented, and the differential diagnosis of this rare scintigraphic finding is discussed.