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An atypical presentation of pulmonary thromboembolism

Lisa Ferraz, Ana Faustino, Andreia Fernandes, Ana Neves

The pulmonary thromboembolism with free-floating right heart thrombus is associated with significant mortality. Echocardiography is essential for rapid diagnosis, helping in treatment decisions. A 79-year-old woman, with history of hypertension and hypercholesterolaemia. Medicated with atorvastatin and lercanidipine. She was admitted to hospital with progressive dyspnea for one week, with worsening in the last days. She was tachycardic, hypotensive and polyneic with oxygen desaturation. Arterial blood gas analysis revealed hypoxemia, hypocapnia and elevated lactates. The electrocardiogram showed sinus rhythm, 95/min. Transthoracic echocardiography revealed severe dilation of the right cavities, with severe dysfunction of the right ventricle and presence of multiple mobile echogenic, spindle-shaped, elongated masses swirling around in the right atria, consistent with multiple thrombus in transit (Video 1). A probable diagnosis of pulmonary thromboembolism was considered, however prior to the initiation of fibrinolytic therapy, the patient had cardiorespiratory arrest in pulseless electrical activity and the advanced life support maneuvers weren’t successful.