PMC4568365_01
12-lead EKG showing right ventricular strain pattern.
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Laboratory findings revealed elevated lactic acid, troponin, d-dimer, and abnormal EKG (Table 1, Figure 1).
Computed Tomographic Pulmonary Angiogram (CTPA) showing massive saddle pulmonary embolus (bold arrow) with hypodense area at the root of pulmonary artery consistent with other emboli (white arrow).
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Urgent CT angiogram showed extensive bilateral pulmonary embolus (Figure 2), and bedside echocardiogram revealed right ventricular (RV) pressure overload with enlarged RV (>41 mm) and mobile echodensity attached to tricuspid valve that appeared to extend into right atrium and ventricle, RHTVE (Figure 3).
Transthoracic echocardiogram, apical 4-chamber view, showing RV pressure overload with enlarged RV diameter (>41 mm) and a long echodensity (embolus) attached to TV extending in both RA and RV (RHTVE); LA: left atrium; RV: right ventricle; RA: right atrium; LV: left ventricle; TV: tricuspid valve; emb: embolus; RHTVE: Right Heart Transvalvular Embolus.
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Urgent CT angiogram showed extensive bilateral pulmonary embolus (Figure 2), and bedside echocardiogram revealed right ventricular (RV) pressure overload with enlarged RV (>41 mm) and mobile echodensity attached to tricuspid valve that appeared to extend into right atrium and ventricle, RHTVE (Figure 3).
Postoperative demonstration of (a) a large (~25 cm) pulmonary embolus en bloc (bold arrow) retrieved from the right and left pulmonary arteries; (b) a long segment of embolus (doted arrow) traversing along tricuspid valve (TV). Both of them were removed in the same open embolectomy under cardiopulmonary bypass procedure.
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On follow-up with the tertiary center, a long segment of blood clot traversing the right atrium and ventricle (Figure 4(b)) and extensive bilateral pulmonary artery embolus (Figure 4(a)) were removed.