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.