Massive Pulmonary Thromboembolism Research Articles

Massive Bilateral Pulmonary Thromboembolism – A Bolt from the Blue Case Report

Thrombosis originating from the deep veins of the lower limbs can result in recurrent emboli leading to acute on chronic pulmonary thromboembolism. The death in such situations would be sudden and unexpected due to acute right sided heart failure (cor pulmonale). There can be few preceding non-specific symptoms such as cough and/or dyspnoea, especially in non-hospitalised decedents. Many a time pulmonary thromboembolism is only detected in a medicolegal autopsy. The sudden and unexpected death in an apparently healthy individual paves the way for a police inquest procedures, and a medicolegal autopsy would be the only legal and logical alternative to find a closure. However, massive bilateral pulmonary thromboembolism occluding almost more than 80 percentage of the pulmonary artery vasculature is an extremely rare phenomenon in a medicolegal autopsy. This case report has been prepared to discuss on such a rare presentation, discovered during the medicolegal autopsy of an apparently healthy 46-year-old individual who collapsed on the sides of a road, and was brought dead to the hospital.

Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: one-year outcomes from a cardiac intensive care unit led shock team program

Abstract Background Mechanical circulatory support (MCS) with peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used for severe cardiogenic shock (CS). Purpose To describe the initial experience with peripheral VA-ECMO within a cardiac intensivist team led program. Methods Retrospective analysis of a short-term MCS prospective registry, from 1 September 2021 to 1 December 2022. Clinical and device related variables were reviewed and reported. We assessed both patient outcomes as well as ECMO-related complications. Results A total of 21 patients were included in this analysis (50 ± 13 years-old, 80% male), ranging from SCAI-C (n = 8) to E (n = 5) and with a median predicted mortality by SAVE score of -4 points [IQ -6 - 0] (corresponding to 30% in-hospital survival). All cannulations were done percutaneously, mostly by trained cardiac intensivists and while at the CICU (n = 12). A femoro-femoral configuration was used for all patients. One patient was cannulated at the referring hospital and retrieved to our unit for further care. Three patients were cannulated during intra-hospital cardiac arrest and one patient was cannulated while breathing spontaneously (awake-ECMO). Mean venous and arterial cannula sizes were 22 ± 1.9 Fr and 17 ± 1.6 Fr, respectively. A 7 French (Fr) arterial limb reperfusion cannula was used in 85% of cases. The most frequent etiology was acute decompensation of chronic heart failure (n = 7), followed by acute myocardial infarction related CS (n = 5), fulminant myocarditis (n = 2) and massive pulmonary thromboembolism (n = 2). A left ventricle venting device was used in 70% of patients [intra-aortic balloon pump (n = 10); percutaneous microaxial pump ( n = 2)] and upgrade to a veno-arterio-venous configuration was necessary in one patient due to differential hypoxemia. Mean ECMO-run duration was 8.4 ± 4.8 days while mean CICU length of stay was 22 ± 17.9 In-hospital mortality was 40%. In survivors, decannulation was surgical in all but one patient. The most frequent strategy was bridge to recovery (n = 14). One patient was bridged directly to heart transplant, one to a temporary centrifugal left ventricular assist device (LVAD) and one to a durable magnetically levitated LVAD. Complications were common and included bleeding from cannula insertion sites (n = 19), renal replacement therapy requirement (n= 10), Harlequin syndrome (n = 2), cardiac tamponade (n = 2), intestinal ischemia (n = 3) and limb ischemia (n = 2). Conclusion VA-ECMO performed by cardiac intensivists is a feasible MCS strategy for severe cardiogenic shock patients in whom mortality, while high, was similar to large international published series. Further experience will allow for improvement in patient selection and minimization of device related complications.ECMO VA 1 year single-center experience

Outcome of massive pulmonary embolism treated only with extracorporeal membrane oxygenation and anticoagulation without thrombolytic therapy or surgical embolectomy.

Although thrombolytic therapy is the standard treatment for massive pulmonary thromboembolism (PTE), it is often ineffective in patients with circulatory collapse. Surgical embolectomy is another treatment option, but whether it is absolutely necessary is controversial. We sought to evaluate the outcomes of patients with massive PTE treated with intensive critical care including extracorporeal membrane oxygenation (ECMO) without thrombolytic therapy or surgical embolectomy. We analyzed 39 patients who were treated for massive PTE from January 2011 to June 2019. Massive PTE was treated with anticoagulation and hemodynamic support at an intensive care unit. ECMO was applied in patients with circulatory collapse. The computed tomography (CT) obstruction index and the ratio of the right ventricle to left ventricle short-axis diameters (RV/LV) were measured using serial CT angiography to confirm changes in pulmonary emboli and RV strain. Twenty-one patients were in cardiogenic shock, and 15 of them needed cardiopulmonary resuscitation (CPR). Fifteen patients were treated with ECMO and nine of them were weaned successfully. The overall in-hospital mortality was 23% (9/39). On the follow-up CT scan after 6 months, residual PTE was observed in 10 patients and their median CT obstruction index was 6.25 % (range 2.5-35). The initial mean RV/LV ratio was 1.8 ± 0.47 and the value measured at follow-up CT decreased to less than 1 (0.9 ± 0.1). Intensive critical care with heparin alone and timely ECMO support without thrombolytic therapy could be an effective treatment option in patients with acute massive PTE.

A 68-Year-Old Man Presenting to the ER with Sudden Dyspnea, A Rare Case of Snowstorm View in the Right Ventricle during Echocardiography

Pulmonary Thromboembolism (PTE) is a fatal condition and the third leading cause of hospital-related deaths. We present a case of acute PTE in a 68 year-old man with dyspnea. Patient had a history of bone malignancy. Bedside echocardiography revealed snowstorm view in the right ventricle. Patient was treated with 10 units reteplase intravenous bolus. Echocardiography was repeated and no signs of snowstorm view were detected. Finally, patient died of cardiogenic shock and massive PTE. In this case we report snowstorm view during echocardiography which is rare and should be considered in clinical assessment of PTE.

The Clinical Importance of C-Reactive Protein to Albumin Ratio (CAR) in Patients with Pulmonary Thromboembolism.

Pulmonary thromboembolism (PTE) commonly arises from lower extremity thrombus and can be fatal if left untreated. To date, many laboratory biomarkers have been used for predicting the prognosis in patients with PTE. C-reactive protein (CRP) to albumin ratio (CAR) is a new biomarker of systemic inflammation. In this study, we aimed to evaluate the clinical importance of CAR in PTE patients. One hundred thirty-three eligible patients who were followed up with the diagnosis of PTE in our hospital between July 2016 and May 2020 were retrospectively evaluated in this study. The patients were divided into three groups as non-massive, sub-massive, and massive PTE. The results of complete blood counts (CBC) and biochemical analysis were evaluated among three groups. Neutrophil, neutrophil to lymphocyte ratio (NLR), D-dimer, troponin, CRP, albumin, and CAR were significantly different among groups. According to multivariate logistic regression analysis, CAR and troponin were determined as the independent predictors of massive PTE. Also, CAR was determined as the only independent predictor of in-hospital mortality in patients with PTE. CAR may be a reliable and easily accessible parameter to determine the severity and prognosis in PTE patients.

Massive Pulmonary Thromboembolism with Clot-in Transit in a Patient with Acute Aortic Dissection and Hemothorax- a Clinician's Dilemma

Acute aortic dissection with hemothorax is an uncommon presentation associated with high mortality and morbidity. They are at increased risk of venous thromboembolism. Massive pulmonary embolism with large clot-in transit has not been previously reported, and its management is not clear.

Massive Hemoptysis and Pulmonary Thromboembolism in a Patient with Pulmonary Tuberculosis: A Therapeutic Conundrum Managed with Bronchial Artery Embolization

Hemoptysis is a crucial entity taking into account its morbidity and mortality. Pulmonary tuberculosis is the leading cause for massive hemoptysis in our part of the world, which if left untreated may be life threatening. We present a case of a 37-year-old male patient with pulmonary tuberculosis with concurrent pulmonary thromboembolism presenting with massive hemoptysis, which was successfully managed with Bronchial Artery Embolization. This case represents that this measure can be a viable therapeutic choice for a patient with a severe life-threatening hemoptysis, particularly when other treatment options are unavailable or ineffective.

Surgical Treatment of a Giant Popliteal Venous Aneurysm and Arteriovenous Fistula on the Adjacent Femoral Vein and Its Postoperative Findings.

A case of a giant popliteal venous aneurysm that caused massive pulmonary thromboembolism with an arteriovenous fistula draining into the adjacent proximal femoral vein is reported herein. Deep veins in the lower leg were occluded by thrombi. The inlet and outlet orifice inside the aneurysm was closed and aneurysmorraphy was performed. The fistula was retained on the estimation that it would maintain the blood flow and prevent thrombus formation inside the femoral vein. The aneurysm was shrunk, the femoral vein was patent, and the fistula was not observed 1 year later, although it still existed 1 week after the operation.

Fibrinolytic treatment with tissue plasminogen activator in a patient with massive pulmonary thromboembolism and bidirectional Glenn procedure

Fibrinolytic treatment with tissue plasminogen activator in a patient with massive pulmonary thromboembolism and bidirectional Glenn procedure

Diagnosis of pulmonary infarction by chest ultrasound in patient with massive pulmonary thromboembolism

Diagnosis of pulmonary infarction by chest ultrasound in patient with massive pulmonary thromboembolism

Duration of Anticoagulation Therapy in Patients with Genetic Inherited Thrombophilia.

Background: Genetic factors play an important role in deep vein thrombosis (DVT). The duration of anticoagulation therapy in patients with verified genetic inheritance and previous events of DVT is still questionable. Case reports: We present three cases of siblings (two brothers and one sister) with verified Venous thromboembolism (VTE) and genetic inheritance. The first case is a 33 y.o. male who was admitted with bilateral massive pulmonary thromboembolism and DVT of the right femoral vein. He had an episode of DVT 4 years ago. Fibrinolytic therapy was introduced immediately. Afterwards, unfractionated heparin was introduced, and then switched to enoxaparin and acenocoumarol. Because of inappropriate INR, it was switched then to rivaroxaban. The imaging methods showed significant improvement, and the patient was discharged from the hospital with rivaroxaban at 2x15 mg/day for another 2 weeks and was instructed to continue 20 mg/day until his next control. In the meantime, the second case, a 36 y.o. male, brother to the first patient, came with vein thrombosis of vena saphena magna of the left leg. Treatment with Acenocoumarol was started and continued for 2 years until complete resolution of the thrombi, and then it was changed to Aspirin. The third case is the sister of the first 2 cases, a 38 y.o female with symptoms and findings almost similar to those in the second case. She was treated with Acenocoumarol for 6 months. Doppler ultrasound showed complete resolution of the thrombosis and anticoagulation therapy was stopped. Genetic investigations for mutation showed presence of homozygous gene mutation for Prothrombin (PTB G20210A) in the first patient, his brother (the second case) was compound heterozygote for PTB and for MTHFR C677T, and his sister (third case) was heterozygous only for the PTB mutation. According to the clinical (recurrent unprovoked DVT with thromboembolic complications) and genetic testing (homozygous gene mutation for PTB) in the first patient, we decided to continue the secondary thromboprophylaxis with rivaroxaban 10 mg/day indefinitely. Conclusion: Testing for genetically inherited thrombophilia should be included in the risk assessment for recurrence, and performed in all patients under 50 y.o. who have a first, non-provoked episode of thrombosis, in order to determine the duration of anticoagulation therapy.

Journey with a 21 weeks primi with acute massive pulmonary thromboembolism secondary to possible “Latent Lupus”: an audacious ride

In pregnancy, the incidence of pulmonary embolism (PE) is increased fivefold when compared to nonpregnant women of the same age, and PE is one of the leading causes of death during pregnancy. However, the diagnosis of PE among pregnant women is complicated by concerns regarding radiation exposure. Systemic lupus erythematosus (SLE) is an autoimmune disorder with a wide array of presentations and a predilection to affect women of certain ethnic backgrounds. The hallmark of the disease is multisystem involvement, dispersed in time and severity. Usual pulmonary involvement includes pleuritis, pleural effusions, pneumonitis, shrinking lung syndrome, pulmonary hypertension, and alveolar hemorrhage. Pulmonary embolism (PE) is a relatively unusual presentation of SLE. We report the case of a 20-year-old primi at 21 weeks gestation with an acute PE with central chest pain and shortness of breath. The absence of overt signs and symptoms and traditional risk factors prompted a fragmentary workup. This led to the detection of antibodies sensitive for SLE, in the absence of overt signs and symptoms. We revive the concept of latent lupus, a condition construed as early lupus. We firmly suspect direct causation between SLE and PE. Further studies are needed to establish pathogenesis to facilitate early diagnosis and prevent morbidity and mortality from PE. Due to persistent hypotension, thrombolytic therapy with streptokinase was administered and the clinical and hemodynamic response was excellent, with no maternal or fetal hemorrhagic complications. The clinical presentation of pulmonary embolism is sometimes camouflaged by the physiological changes that occur in pregnancy and diagnosis is often delayed by a reluctance to expose the fetus to ionizing radiation.

Abstract 17233: Primary Intimal Sarcoma Of The Pulmonary Artery In A Patient With Laboratory Confirmed Heterozygous Factor V Leiden Mutation: A Case Report

Pulmonary artery intimal sarcoma (PAIS) is a rare tumor associated with progressively increasing dyspnea, atypical chest pain, and pulmonary hypertension. Owing to overlap in presentation, PAIS can be misdiagnosed as pulmonary thromboembolism (PTE). Here we present the case of a 59-year-old male with heterozygous Factor V Leiden mutation, history of deep vein thrombosis (DVT), and recent PTE presenting to urgent care with cough, mild orthopnea, and exertional dyspnea. Transthoracic echocardiogram (TTE) revealed severely dilated right ventricle with moderately decreased function and severe pulmonary hypertension with pulmonary arterial (PA) pressure of 93mmHg. Computed tomography angiography of the chest revealed massive central PTE. Given hemodynamic stability, saturating well on room air and simplified PESI score of 0, Pulmonology recommended discharge with anticoagulation. The patient returned a month later with three weeks of increased dyspnea on exertion, worsened right ventricular function as well as possible new mobile thrombus extending into the right ventricular outflow tract (RVOT). Due to presumed failure of medical therapy, Cardiology placed the patient on venoarterial extracorporeal membrane oxygenation (VA-ECMO) followed by attempted mechanical thrombectomy using both the Angiovac and Penumbra CAT12 systems. Both systems failed to remove substantial material from the PA. The next day, TTE revealed increased PA pressure of 132mmHg.The patient underwent emergent bilateral thromboendarterectomy with a mass discovered involving the pulmonary valve (PV), RVOT, both left and right PAs, along with invasion into the PA wall. The mass was resected, the PV valve replaced, the main PA and left PA reconstructed, and pericardial patch reconstruction of the RVOT was performed. The mass was determined to be a PAIS of French Federation of Comprehensive Cancer Centres (FNCLCC) Grade 3. Two months after uncomplicated recovery, chemotherapy was initiated. Securing the diagnosis of PAIS is challenging. However, collaboration between clinicians, radiologists, and pathologists increases the likelihood of recognizing subtle markers that can differentiate PAIS from illnesses with a similar presentation.

Thyroidectomy in patients with amiodarone-induced thyrotoxicosis

The OBJECTIVE of the study was to analyze the experience of performing thyroidectomy (TE) in patients with amiodarone-induced thyrotoxicosis (AmIT) at our centre.METHODS AND MATERIALS. The study included 12 patients with AmIT who underwent TE. Medical records were analyzed to assess the features of the AmIT and indications for TE. We also studied the operation protocols and postoperative follow-up data. Intraoperative, early and long-term postoperative complications were recorded. The long-term TE results were evaluated by the dynamics of the left ventricular ejection fraction (LVEF) based on the echocardiography data.RESULTS. The main indications for TE included the resistance of thyrotoxicosis to medication and worsening of the cardiac pathology. No cases of thyrotoxicosis progression or thyrotoxic crisis were registered during the operation. The vocal cord paresis developed in one case, completely restored in a year. Blood loss was minimal in all cases. Other intraoperative complications were absent. Not a single death was registered in the early postoperative period. At this period, a short paroxysm of atrial fibrillation resolved on its own was registered in patient with arrhythmogenic right ventricular dysplasia. A patient with biventricular chronic heart failure of a high functional class died 39 days after the operation due to a massive pulmonary thromboembolism. The long-term results of TE were evaluated in eight patients. In four out of five patients with initially reduced LVEF, it increased. In three patients with initially normal LVEF, it did not change.CONCLUSION. Thyroidectomy is an effective and safe treatment in patients with AmIT, including those with the persistent thyrotoxicosis and severe cardiac pathology. The success is possible when the preparation of patients for the intervention is carried out by a team of specialists experienced in treating of such patients.

MO926RAPID VS. LATE RE-TRANSPLANTATION FOR EARLY KIDNEY GRAFT LOSS

Abstract Background and Aims Early graft failure (EGL) is a devastating complication of kidney transplantation. Patients with EGL have an increased risk of mortality of up to twelve times compared to patients who received grafts that survive beyond 30 days. Moreover, they may have become sensitized to antigens from the failed graft and that human leukocyte antigen antibodies (anti-HLA), identified on single antigen bead assays, may not be reliable until several weeks after transplantation. Thus, if rapid re-transplantation occurs, there is no certainty regarding the recipient's immunological status. Hence, there could be an increased immunological risk with the consequent disturbance of the new graft's survival. Method We performed a retrospective single-center observational study in re-transplanted patients with EGL (defined as graft loss before 30 days from transplant) between January 1977 and November 2019 from our center to analyze the outcomes of rapid re-transplantation (occurred within 30 days of EGL) vs late re-transplantation (occurred beyond those 30 days). Results: T here were 82 re-transplants after EGL. The median overall patient survival after re-transplantation was 32 years. Eight patients died within the first year. Among the mortality causes, there were four septic shocks, one cardiogenic shock, one massive pulmonary thromboembolism, one myocardial infarction, and one unknown cause. When analyzed for periods, death censored graft survival was 89% at one and five years after re-transplantation. One graft was lost at eight days due to antibody-mediated rejection (AMR), while there was one death with a functioning graft three months after re-transplantation secondary to a pulmonary embolism. Seventy-three late re-transplants occurred. When analyzed for periods, death censored graft survival was 81% and 69% at one and five years after re-transplantation, respectively. The median patient survival after late re-transplantation was 32 years. There were fewer deaths after rapid re-transplantation than late re-transplantation, but given the small number of cases in the former, this difference did not reach statistical significance (p = 0.3). There was no association between the timing of re-transplantation and an increased risk of graft failure (HR 0.30 [0.04 – 2.2]). While four rapid re-transplants did not share any incompatibilities between donors, four did share at least one HLA type I incompatibility, and one shared an incompatibility of HLA class I and class II. There were no T-cell mediated rejections (TCMR), and there was only one AMR in the rapid rapid re-transplantation group, whereas there were six TCMRs and fifteen AMRs in the late re-transplantation group (p = 0.03 and p = 0.4, respectively). Conclusion Rapid re-transplantation appears to be safe and does not entail increased rejection risk, nor it diminishes long-term graft survival when compared to late re-transplantation.

Double inferior vena cava filter implantation in a patient with duplication of the inferior vena cava

An 84-year-old-woman was admitted because of syncope and dyspnea. She also required surgery for lumbar disc herniation. Computed tomography revealed bilateral massive pulmonary thromboembolism, deep vein thrombosis, and duplication of the inferior vena cava (IVC) in which the left IVC had merged with the left renal vein. Two retrievable IVC filters were deployed in both IVCs, and direct oral anticoagulant therapy was started. After orthopedic surgery for the lumbar disc herniation, the IVC filters were retrieved. No complications occurred. Different treatment strategies could be required for IVC filter implantation in a patient with duplication of the IVC.

POCUS echocardiography in massive pulmonary thromboembolism as a first manifestation of COVID-19 infection: a case report

Introduction: COVID-19 infection significantly increases the risk for thromboembolic complications which can cause multi organ dysfunctions and worsen patients clinical course and prognosis 1-3 Case report: We are presenting a 73-years-old patient admitted to ICU unit due to first episode of sudden dyspnea, syncope and chest pain He has no history of previous cardiovascular or respiratory disease, no history of thromboembolism (PTE) or deep vein thrombosis (DVT) ECG showed atrial fibrillation with HR 120 bpm and incomplete RBBB Blood pressure was 85/45mmHg with cold periphery Patient denied any provocable PE risk factors Bed site POCUS (Point-of-Care Ultrasound) echocardiography was performed immediately in order to evaluate the cause of patient symptoms and hemodynamic instability Examination showed increased right ventricle (RV) size, reduced RV function (TAPSE 13, TDI S’ 9), presence of McConnell’s sign, severe tricuspid regurgitation with dilated v cava and signs of pulmonary hypertension Due to hemodynamic instability and indirect signs of the presence pf pulmonary embolism fibrinolysis with alteplase infusion was applied Patient hemodynamically stabilized after first hour Nasopharyngeal smear for SARV CoV-2 was taken due to ongoing pandemic and result come out positive for virus RNK (real-time fluorescence polymerase chain reaction-PCR) CT angiography was performed which showed large intraluminal thrombi in the right pulmonary artery, extending to left pulmonary artery up to subsegmental level His D-dimer values were 7813 ng/ml, CRP 123 mg/L Evaluated sPESI score was 2, which indicated elevated 30-day death risk Patient remained clinically stable He was transferred to the infectious disease clinic for further treatment After two weeks was discharged with recommendations for three months anticoagulation treatment with Rivaroxaban Patient performed control visit at our clinic after four months He was stable, asymptomatic with normal right ventricular function Conclusion: This is case of successful treatment of pulmonary embolism complicated with cardiogenic shock as a first manifestation of COVID-19 infection at our clinic since the start of pandemic POCUS echocardiography is fast noninvasive method that help us urgently assess the cause of patient instability and guide diagnostic approach and patient management [ABSTRACT FROM AUTHOR] Copyright of Cardiologia Croatica is the property of Croatian Cardiac Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use This abstract may be abridged No warranty is given about the accuracy of the copy Users should refer to the original published version of the material for the full abstract (Copyright applies to all Abstracts )

Clinical Significance and Prognosis of Right Heart Thrombi Associated With Acute Pulmonary Thromboembolism - Results of a Multicenter Registry of Thrombolysis in Japan.

Thrombolytic therapy is standard treatment in acute pulmonary thromboembolism (PTE) with hemodynamic instability. Although right heart thrombi (RHT) appear to increase mortality in acute PTE, large-scale studies of acute PTE with RHT are scarce.Methods and Results:Patient data (from August 2005 to May 2014) obtained from post-marketing surveillance of thrombolytic therapy using a tissue-type plasminogen activator were analyzed retrospectively. Of the 2,698 confirmed cases of acute PTE who underwent echocardiographic assessment, 166 (6.2%) were diagnosed with RHT. PTE patients with RHT, compared with those without RHT, had higher rates of mortality (20.2% vs. 10.4%, P<0.001), hemodynamic instability (53.0% vs. 37.7%, P<0.001), and PTE recurrence (6.6% vs. 2.3%, P=0.003). When considering PTE-related hemodynamic severity (cardiopulmonary arrest/collapse, massive, submassive, and non-massive), mortality was significantly higher in patients with RHT in the massive (19.8% vs. 7.7%, P=0.002) and submassive (8.0% vs. 2.8%, P=0.018) groups, whereas no significant differences was found between those with and without RHT in the cardiopulmonary arrest/collapse (51.7% vs. 52.1%, P=0.960) and non-massive (1.6% vs. 0%, P=0.596) groups. PTE patients with RHT had higher mortality, severity, and PTE recurrence rates. RHT was particularly associated with worse outcomes in patients with massive or submassive PTE.

Successful systemic fibrinolysis in a patient with Covid- 19: Case report

The new coronavirus 2019-nCov or SARS-Cov-2 is responsible for the most important pandemic in the 21st century: the coronavirus disease (COVID-19).&#x0D; The 2019-nCov infection elicits a hyper-coagulable state, conditioning a worse outcome in these patients. The pathophysiology of the exaggerated coagulation activation in these patients is still unknown, and probably involves several mechanisms, different from those involved in sepsis-associated coagulopathy.&#x0D; This article discusses the case of a patient with no remarkable medical history, who after 7 days of fever, diarrhea and epigastric pain was diagnosed with COVID-19 bilateral pneumonia, further aggravated by severe Acute Respiratory Distress Syndrome. In this context, the patient experienced a massive acute pulmonary thromboembolism accompanied by an acute thrombus in the heart’s right ventricle, leading to hemodynamic instability. For the first time in our center in these patients, systemic fibrinolysis was successfully performed, with resolution of the intracavitary thrombus and the acute hemodynamic shock.

Successful Treatment of Massive Pulmonary and Venous Thromboembolism with Intravenous Heparin in a Patient with Mild Membranous Nephropathy.

Membranous nephropathy is well described to be associated with hypercoagulable state. Pulmonary embolism is a common occurrence with hypercoagulability and early recognition and prompt treatment including thrombolysis is warranted. We present here a case of massive thrombus in the pulmonary trunk and inferior vena cava in a patient with membranous nephropathy where anticoagulation with heparin was continued with successful resolution over time. We discuss the pros and cons of anticoagulation amangement in such patients and review the literature.