Pulmonary Thromboembolism – A Clinical Report A Combination of Different Therapeutic Strategies

1. Abstract 1.1. Background: Pulmonary embolism (PE) is common and can be fatal. For rapid diagnosis and adequate treatment, it is essential to have a high index of suspicion, essential elements for a favorable outcome and low mortality. 1.2. Case Presentation: A 79-year-old man presented with syncope and was diagnosed with pulmonary embolism. The initial therapeutic strategy was low molecular weight heparin (LMWH). Given the worsening with hemodynamic instability, systemic thrombolysis was performed, and clinical improvement was observed. As the patient remained in shock with the need for vasoactive amines, and due to the maintenance of proximal pulmonary thrombi, catheter-directed percutaneous thrombectomy was performed, which when fragmenting and aspirating the thrombi, reversed the right heart failure with rapid hemodynamic improvement. 1.3. Conclusion: This case included the combination of different strategies, allowing the patient's survival and, probably, a faster subsequent recovery of the optimized cardio-respiratory function. 2. Introduction Pulmonary embolism (PE) is common and can be fatal4. According to European Society of Cardiology, the annual incidence rate of PE varies between 39-115 per 100.000 inhabitants [3]. The clinical presentation of a patient with PE is variable and nonspecific4, representing a clinical challenge. Therefore, it is essential to have a high index of suspicion. 3. Case Report A 79-year-old man, previously under hypocoagulation with rivaroxaban for suspected Deep Venous Thrombosis (DVT) of the right lower limb 3 years earlier. Admitted to the emergency department due to a syncope with Traumatic Brain Injury (TBI). No dyspnea or chest pain. On admission, Glasgow Coma Scale 15, without focal deficits, presenting a hematoma in the left occipital region, blood pressure (BP) 117/82mmHg, heart rate 99bpm, peripheral oxygen saturation 94% under oxygen therapy at 2L/min, tachypnoea, slight asymmetry of the lower limbs with pre-tibial edema on the left, although without tightness in the calf. Arterial blood gas analysis in room air revealed respiratory alkalemia and hypoxemia (pH 7.51, pCO2 28mmHg, pO2 76mmHg), normal lactate and glucose. D-dimers 14.03mg/dL, troponin 1.01ng/dL. Chest radiography was normal, electrocardiogram in sinus rhythm with the S1Q3T3 pattern (Figure1). Head computed tomography (CT), showed an epicranial hematoma. A chest Computed Tomography Pulmonary Angiography (CTPA) revealed endoluminal repletion defects in both the right and left pulmonary arteries (Figure2A) and its lobar and segmental branches, in relation to central and segmental Pulmonary Thromboembolism (PTE) and dilation of the right cardiac chambers (RCs) with contralateral bulging of the interventricular septum. Transthoracic Echocardiography (TTE) showed dilation of the RCs.