Case presentation
A 74-year-old man was admitted to our hospital with a 12-day history of
decreased exercise capacity and dyspnoea. At presentation, he was
afebrile with a blood pressure of 130/110 mmHg, heart rate of 80/min and
respiratory rate of 20/min. The physical
examination was within normal limits.
Electrocardiography showed sinus rhythm with first degree
atrioventricular block, S wave in lead I, q wave and inverted T wave in
lead III(Figure1). Laboratory evaluation was significant for elevated
D-dimer of 4450.08ng/ml and brain natriuretic peptide level of 4398
ng/l. Complete blood count and coagulation studies were within normal
limits. Tranthoracic echocardiography was performed. Right ventricular
(RV) dysfunction was defined as dilatation of the right ventricle
(right/left ventricle diameter ratio 1.2 in the apical four chamber
view) combined with elevated systolic gradient through the tricuspid
valve (53mm Hg), lack of relevant left ventricular (LV) dysfunction or
valvular heart disease. Further evaluation with transthoracic
echocardiography revealed a pulmonary artery clot of about 19.8mm*32.2mm
seen at the right pulmonary artery, 21mm from the bifurcation of the
pulmonary artery (Figure2. Panels A
and B, Video 1, 2). Meanwhile, venous Doppler studies of bilateral lower
extremities showed right popliteal vein thrombosis. Computed tomography
pulmonary angiography (CTPA) revealed several pulmonary emboli in right
pulmonary artery (Panel C).The patient was diagnosed intermediate risk
APE as systemic systolic blood pressure on admission ≥90 mmHg with
echocardiographic right ventricular overload and elevated serum levels
of BNP. The patient was started on anticoagulation with low molecular
weight heparin and oral warfarin. Tranthoracic echocardiography was
re-evaluated after 11 days. The RV diameter was decreased combined with
pulmonary artery thrombus decreased to 10.9mm*13mm (Panels D and E,
Video 3, 4). The systolic gradient through the tricuspid valve was
43mm Hg. The patient showed significant clinical improvement and was
discharged home after being transitioned to oral warfarin.