Saddle pulmonary embolism: right ventricular strain an indicator for early surgical approach

Namana, Vinod; Siddiqui, Sabah; Balasubramanian, R; Sarasam, Rajeswer; Shetty, Vijay

doi:10.1093/omcr/omw045

Cited by 7 publications

(11 citation statements)

References 15 publications

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“…Saddle pulmonary embolism is a medical emergency manifesting as a large clot with the potential for causing sudden hemodynamic collapse, and as many as 25% present as sudden death out of more than 100,000 cases reported annually (Nama et al 2016). Though CTA exists as the gold standard for diagnosis of pulmonary emboli, patients may have contraindications to such a modality.…”

Section: Resultsmentioning

confidence: 99%

The unfortunate miss: a saddle pulmonary embolism

Gruca¹,

Madhira²

2017

IJM

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Pulmonary embolism is a potentially life-threatening condition that requires prompt diagnosis and efficient management such as in the form of thrombolysis or surgical thrombectomy. Saddle pulmonary emboli occurring at the bifurcation of the pulmonary artery are especially dangerous as they put afflicted individuals at risk for sudden hemodynamic collapse. While CT Angiography at present is the current imaging modality of choice, times exist when they are contraindicated and V/Q scintigraphy is used as the choice alternative. We present a rare catastrophic case of a saddle pulmonary embolism in an individual with a low-probabilityinterpretation on V/Q scintigraphy despite a clear depiction of the thrombus on echocardiography.Keywords: Pulmonary; Embolus; Thrombus; Thrombolysis; Echocardiogram. ReleasesThis article has never been published previously, and it is not under consideration from publication elsewhere. The publication is approved by all authors and tacitly by the responsible authorities where the work was carried out, and if accepted, it will not be published elsewhere including electronically in the same form, in English or in any other language, without the written consent of the copyright-holder. CaseOur patient was a 70-year-oldfemale with a history of COPD, paroxysmal atrial fibrillation, congestive heart failure (HFrEF), type 2 diabetes mellitus, and non-small cell lung carcinoma (NSLCL) who presented with symptoms of bilateral lower extremity swelling, dyspnea on exertion and generalized weakness. Admitted for acutely decompensated heart failure, there was some suspicion for pulmonary embolism (PE) as the patient experienced oxygen saturation of 90% despite supplemental oxygen.Her other vital signs were otherwise unremarkable save for a heart rate of 121 beats/minute. Pertinent physical examination findings included elevated jugular venous pressure at 5 cm above the sternal angle, bibasilar pulmonary fine crackles, and bilateral lower extremity 1+ pitting edema. Because of an allergy to contrast dye and low Well's score, a V/Q scan was opted for in lieu of thoracic computed tomography angiography (CTA) with results suggesting low probability of a PE as there were matching perfusion and ventilation defects (Figure 1). A subsequent echocardiogram performed showed extensive right ventricular (RV) dilatation with interventricularseptal bowing and an echogenic focus in the pulmonary artery (PA) concerning for a saddle PE (Figures 2 and 3). However, despite intravenous heparin infusion, the patient decompensated with acute hypoxemic respiratory failure and died after comfort care measures were agreed upon.

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Section: Resultsmentioning

confidence: 99%

The unfortunate miss: a saddle pulmonary embolism

Gruca¹,

Madhira²

2017

IJM

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“…The right ventricular dysfunction on echocardiogram has an important role for prognosis as seen in different studies that show a correlation between adverse outcomes and right ventricular dysfunction in pulmonary embolism [ 22 ]. Although in our study we did not study the correlation of RV dysfunction with adverse outcomes, it can however be used to risk-stratify patients with acute PE [ 23 ].…”

Section: Discussionmentioning

confidence: 99%

Elevated D-Dimers and Right Ventricular Dysfunction on Echocardiography for Diagnosis of Pulmonary Embolism: A Validation Study

Khan

Javed

Mohsin

et al. 2020

Cureus

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Background There is an increasing need to explore other non-invasive techniques for the diagnosis of pulmonary embolism in resource-limited countries. Objective To assess the validity of elevated D-dimer levels and right ventricular (RV) dysfunction on echocardiography in predicting definite massive pulmonary embolism among patients diagnosed with massive pulmonary embolism using computed tomography (CT) pulmonary angiography as the gold standard. Methods The patients with acute massive pulmonary embolism on CT pulmonary angiography were included. The participants underwent 12-lead electrocardiography, assessment of D-dimer levels, and bedside echocardiography to determine right ventricular dysfunction. The data were recorded on a proforma and analyzed using IBM SPSS software version 26.0 (IBM Corp., Armonk, NY). Results There were 160 patients in the study. The mean age was 49.19 ± 14.89 years. Elevated D-dimer levels were seen in 80.60% of the patients whereas ventricular dysfunction on echocardiography was seen in 90.00% of the patients. The sensitivity and specificity of elevated D dimer levels were 78.99% and 14.60%, respectively. The positive predictive values (PPV) and negative predictive values (NPV) for elevated D-dimer levels were 72.87% and 19.35%, respectively. In contrast, the sensitivity of ventricular dysfunction was 94.96% and specificity 24.39%. PPV was found to be 78.47% and NPV was 62.50%. Conclusion Positive D-dimer levels and ventricular dysfunction on echocardiography are sensitive enough to consider the diagnosis of massive pulmonary embolism but lack adequate specificity, thus, necessitating the presence of other noninvasive tests.

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“…Two such cases recently published in the Journal provide an insight into the successful treatment of clinically challenging presentations of intermediate to high and high-risk PE, one using thrombolysis [ 3 ] and the other surgical embolectomy [ 4 ].…”

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confidence: 99%

“…The second case by Namana et al . [ 4 ] reports the case of a 47-year-old female with a saddle embolus extending into both main pulmonary arteries causing RV dysfunction without haemodynamic instability. A decision was made to proceed with surgical embolectomy, following which she recovered well, with improving RV function and discharged home 6 days later.…”

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confidence: 99%

“…With such extensive thrombus as shown in figure 5 in the case by Namana et al . [ 4 ], thrombolysis is unlikely to attain complete clot lysis, and a significant proportion of these patients will have residual thrombus, placing them at risk of suboptimal initial benefit and chronic thromboembolic disease; potentially requiring further surgical intervention when clot extraction is more difficult, pulmonary hypertension is established and RV function is permanently impaired.…”

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