Images in Clinical Medicine
Thrombolysis of a Massive Pulmonary Embolism
N Engl J Med 2002; 347:1161October 10, 2002
- Article
Figure 1 A 52-year-old man with chronic left bundle-branch block presented with exertional syncope but no chest pain, palpitations, or dyspnea. His blood pressure was 95/60 mm Hg, and examination revealed signs of right ventricular failure and ascites. Transthoracic echocardiography revealed right ventricular dilatation and hypokinesis, with moderate tricuspid regurgitation and an estimated right ventricular systolic pressure of 55 mm Hg. Doppler studies of the legs showed bilateral proximal deep venous thrombosis, making the diagnosis of pulmonary embolism likely. Paracentesis and cytologic analysis of ascitic fluid revealed metastatic adenocarcinoma. Seven days after presentation, the patient had multiple episodes of arterial desaturation and increasing oxygen requirements despite ongoing anticoagulation with heparin. An urgent computed tomographic angiogram showed a large saddle embolus at the bifurcation of the main pulmonary artery, with extension into the right and left pulmonary arteries (arrow in Panel A). After treatment with intravenous tissue plasminogen activator, the patient's respiratory status dramatically improved over a period of several hours, and approximately 24 hours later, computed tomography demonstrated resolution of the saddle embolus (Panel B). Repeated echocardiography showed that the right ventricular systolic pressure had decreased to 36 mm Hg. The patient subsequently received an inferior vena caval filter, with no clinical recurrence of pulmonary embolism.
Neil P. Fam, M.D.
Atul Verma, M.D.
Toronto General Hospital, Toronto, ON M5G 2C4, Canada
