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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
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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
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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.
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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.
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