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Images in Cardiovascular Medicine Massive Pulmonary Embolization Diagnostic and Therapeutic Images Robert C. Hendel, MD; Aaron Satran, MD; Jonathan Hoffberger, MD; Edward B. Savage, MD A Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017 activator was initiated, and catheter extraction of the emboli was attempted without success. Serial pulmonary angiography revealed only minimal clot resolution; however, hemoptysis ensued. The patient’s respiratory status deteriorated, requiring 100% oxygen and then intubation. Echocardiography demonstrated right ventricular enlargement and dysfunction (Figure 3). On the basis of the presence of hemodynamically compromising pulmonary embolism and right ventricular dysfunction in the setting of ineffective clot lysis, the patient was referred for surgical embolectomy. In the operating room before sternotomy, an inferior vena caval filter was placed. During this procedure, hypotension and bradycardia occurred, and the patient was placed on cardiopulmonary bypass. A large amount of thrombus was subsequently removed from the pulmonary artery (Figure 4). The patient survived without sequelae and is currently doing well without functional compromise. 44-year-old man who had undergone 3-vessel coronary artery bypass graft surgery 1 week earlier presented with a 1-day history of dyspnea at rest and near syncope. His physical examination was remarkable for tachycardia (134 bpm) and tachypnea (rate⫽34). Cardiac and pulmonary examinations were otherwise normal. Chest radiography was unremarkable except for postsurgical cardiac changes. The ECG demonstrated sinus tachycardia and an SI,QIII,TIII pattern (Figure 1), suggestive of pulmonary embolization. Laboratory examination showed a total leukocyte count of 17 500, hemocrit value of 10.8 g, and D-dimer at ⬎40. Concern for pulmonary embolism prompted therapy with heparin. CT with contrast (Figure 2) revealed a large thrombus in the main pulmonary artery. Systolic blood pressure decreased to ⬇100 mm Hg, but because of the patient’s recent surgery, systemic thrombolytic therapy was felt to be contraindicated. A local infusion of tissue-type plasminogen Figure 1. Admission ECG demonstrating SI,QIII,TIII pattern. From the Departments of Medicine (R.C.H., A.S.) and Cardiovascular-Thoracic Surgery (J.H., E.B.S.), Rush-Presbyterian–St. Luke’s Medical Center, Chicago, Ill. Correspondence to Robert C. Hendel, MD, 1725 W Harrison Ave, PO Box 020, Chicago, IL 60612. E-mail [email protected] The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine. Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030. (Circulation. 2003;107:e224-e225.) © 2003 American Heart Association, Inc. Circulation is available at http://www.circulationaha.org DOI: 10.1161/01.CIR.0000069946.71791.37 1 2 Circulation July 1, 2003 Figure 4. Fragments of thrombus removed from the pulmonary artery, including 1 V-shaped segment removed from the bifurcation of the pulmonary artery. Scale at bottom is in inches. Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017 Figure 2. CT scan depicting a large thrombus (arrow) straddling the bifurcation of the main pulmonary artery (“saddle” embolus). Figure 3. Four-chamber view of the echocardiogram demonstrating marked dilation of the right atrium (RA) and right ventricle (RV). LA and LV indicate left atrium and left ventricle, respectively. Massive Pulmonary Embolization: Diagnostic and Therapeutic Images Robert C. Hendel, Aaron Satran, Jonathan Hoffberger and Edward B. Savage Circulation. 2003;107:e224-e225 doi: 10.1161/01.CIR.0000069946.71791.37 Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2003 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/107/25/e224 Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/