A case of saddle pulmonary embolus visualized on a transthoracic echocardiography in a 69-year-old female

IMAGING COLUMN

A case of saddle pulmonary embolus visualized on a transthoracic echocardiography in a 69-year-old female

Dilli Ram Poudel, MD1*, Smith Giri, MD2, Ranjan Pathak, MD1, Inyong Hwang, MD2 and Shadwan Alsafwah, MD, FACC2

1Department on Internal Medicine, Reading Health System, West Reading, PA, USA; 2Department on Internal Medicine, University of Tennessee Health Science Center, Memphis, TN, USA

Abstract

A 69-year-old female with history of immobilization presented with shortness of breath and generalized weakness and was found to have large saddle pulmonary embolus on CT scan. Further evaluation with a transthoracic echocardiography revealed a moderately enlarged and hypokinetic right ventricle with a pulmonary artery clot of about 1.5 cm seen at the bifurcation while the ultrasound of the legs was negative for deep vein thrombosis.

Keywords: saddle; pulmonary; embolism; anticoagulation; echocardiogram

Citation: Journal of Community Hospital Internal Medicine Perspectives 2016, 6: 31058 - http://dx.doi.org/10.3402/jchimp.v6.31058

Copyright: © 2016 Dilli Ram Poudel et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 20 January 2016; Revised: 3 March 2016; Accepted: 4 March 2016; Published: 25 April 2016

*Correspondence to: Dilli Ram Poudel, Department of Medicine, Reading Health System, 6th Avenue and Spruce Street, Reading, PA 19611, USA, Email: dr.dillirampoudel@gmail.com

 

A 69-year-old, white, hypertensive female presented with dizziness, shortness of breath, and generalized weakness. Computed tomography (CT) of the chest revealed a large saddle pulmonary embolus (PE) with extensive clot burden. The patient reported staying immobilized for the preceding 7 weeks due to her knee osteoarthritis flare. There was no history of deep vein thrombosis (DVT) or pulmonary embolism (PE). She had occasionally smoked in the past but quit 6 years back.

At presentation, she was afebrile with a blood pressure of 136/78 mmHg, heart rate of 68/min, respiratory rate of 24/min, and an oxygen saturation of 97% on 2 L nasal cannula. Physical examination revealed an obese female in no acute distress. Lung exam revealed bilateral wheeze and mildly increased work of breathing. She had trace pitting edema in her bilateral legs. Rest of the physical examination was within normal limits. Complete blood count and coagulation studies were within normal limits.

Laboratory evaluation was significant for mildly elevated troponin of 0.8 ng/ml and brain natriuretic peptide (BNP) level of 4,609 ng/ml. Further evaluation with transthoracic echocardiography revealed a moderately enlarged and hypokinetic right ventricle with a pulmonary artery clot of about 1.5 cm seen at the bifurcation (Fig. 1, Video 1). Meanwhile, venous Doppler studies of bilateral lower extremities did not show any evidence of DVT.

Fig 1

Fig. 1. Transthoracic echocardiographic image showing saddle pulmonary embolus of about 1.5 cm size (arrow) in the main pulmonary artery near its bifurcation.

Video Clip 1.  Real-time video clip of transthoracic echocardiogram showing a freely mobile saddle pulmonary embolus in the main pulmonary trunk near its bifurcation.

Due to extensive clot burden and evidence of right ventricular strain, the patient was given 80 mg of intravenous alteplase and started on anticoagulation with heparin drip. Patient showed significant clinical improvement in the next few days and was discharged home after being transitioned to oral warfarin.

About The Authors

Dilli Ram Poudel
Department of Internal Medicine, Reading Health System
United States

Department of Internal Medicine, PGY2

Smith Giri
Department of Internal Medicine, University of Tennessee Health Science Center
United States

Ranjan Pathak
Department of Internal Medicine, Reading Health System
United States

Inyong Hwang
Department of Internal Medicine, University of Tennessee Health Science Center
United States

Shadwan Alsafwah
Department of Internal Medicine, University of Tennessee Health Science Center
United States

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