Jean Liew1, Janelle Stevens2, Christopher Slatore3. 1. Fellow Physician in the Division of Rheumatology in the Department of Medicine at the University of Washington in Seattle. jwliew@uw.edu. 2. Fellow Physician in the Division of Pulmonary and Critical Care Medicine in the Department of Medicine at Oregon Health & Science University in Portland. stevejan@ohsu.edu. 3. Associate Professor in the Section of Pulmonary and Critical Care Medicine in the Veterans Affairs Portland Health Care System in OR, and an Attending Physician in the Division of Pulmonary and Critical Care Medicine in the Department of Medicine at Oregon Health & Science University in Portland. slatore@ohsu.edu.
Abstract
INTRODUCTION: Acute pulmonary embolism is the third leading cause of cardiovascular death. Management options include anticoagulation with or without thrombolysis. Concurrent persistent hypoxemia should be a clue to the existence of an intracardiac shunt. CASE PRESENTATION: A 46-year-old man experienced acute hypoxemic respiratory failure requiring mechanical ventilation after anesthesia induction for elective hip arthroplasty. He was found to have submassive bilateral pulmonary emboli with acute right ventricular dysfunction and a coexisting patent foramen ovale with right-to-left shunt. He remained profoundly hypoxemic despite catheter-directed thrombolysis. He underwent surgical embolectomy with partial endarterectomy, resulting in clinical improvement. DISCUSSION: The management of acute submassive pulmonary embolism is undertaken on an individualized basis because of the wide spectrum of clinical presentations. In this report we review the literature and discuss the evidence behind the management of cases of acute pulmonary embolism complicated by hypoxemia from a patent foramen ovale. In a case of acute pulmonary embolism complicated by refractory hypoxemia from an intracardiac shunt, adjunctive therapies in addition to anticoagulation and thrombolysis must be considered.
INTRODUCTION: Acute pulmonary embolism is the third leading cause of cardiovascular death. Management options include anticoagulation with or without thrombolysis. Concurrent persistent hypoxemia should be a clue to the existence of an intracardiac shunt. CASE PRESENTATION: A 46-year-old man experienced acute hypoxemic respiratory failure requiring mechanical ventilation after anesthesia induction for elective hip arthroplasty. He was found to have submassive bilateral pulmonary emboli with acute right ventricular dysfunction and a coexisting patent foramen ovale with right-to-left shunt. He remained profoundly hypoxemic despite catheter-directed thrombolysis. He underwent surgical embolectomy with partial endarterectomy, resulting in clinical improvement. DISCUSSION: The management of acute submassive pulmonary embolism is undertaken on an individualized basis because of the wide spectrum of clinical presentations. In this report we review the literature and discuss the evidence behind the management of cases of acute pulmonary embolism complicated by hypoxemia from a patent foramen ovale. In a case of acute pulmonary embolism complicated by refractory hypoxemia from an intracardiac shunt, adjunctive therapies in addition to anticoagulation and thrombolysis must be considered.
Authors: Navkaranbir S Bajaj; Rajat Kalra; Pankaj Arora; Sameer Ather; Jason L Guichard; W Jake Lancaster; Nirav Patel; Fabio Raman; Garima Arora; Firas Al Solaiman; D Trey Clark; Louis J Dell'Italia; Massoud A Leesar; James E Davies; David C McGiffin; Mustafa I Ahmed Journal: Int J Cardiol Date: 2016-09-20 Impact factor: 4.164
Authors: Robert C Neely; John G Byrne; Igor Gosev; Lawrence H Cohn; Quratulain Javed; James D Rawn; Samuel Z Goldhaber; Gregory Piazza; Sary F Aranki; Prem S Shekar; Marzia Leacche Journal: Ann Thorac Surg Date: 2015-07-10 Impact factor: 4.330