ElectricPE: The Diagnosis of Pulmonary Embolism: Case Study 30
Jeffrey R. Galvin, M.D. and James J. Choi, B.S.
Peer Review Status: Internally Reviewed
His chest x-ray revealed borderline cardiac enlargement.
A cardiac echo was obtained to further investigate the cause of the patients dyspnea. The short axis view showed marked dilatation of the right ventricle.
The intraventricular septum indents the left ventricle during
systole indicating high pressures in the right ventricle. These
findings are confirmed on the 4 chamber view.
In addition the color Doppler shows marked regurgitation of blood
flow through the tricuspid valve.
The
diagnosis based on the echocardiogram was pulmonary hypertension of
unknown etiology.
A chest CT (mediastinal windows) revealed clots distending both
the right and left main pulmonary arteries.
A neutral
axis CT view of the heart confirmed the presence of an enlarged right
ventricle. 
The inferior vena cava was distended and contrast distribution was
inhomogenous raising the possibility of clot in the Inferior Vena
Cava. 
Ultrasound examination of the IVC
and both
legs showed that the inferior vena cava was patent as were the
hepatic veins.
The iliac vessels and the right deep veins of the leg were easily
compressed confirming that they were patent.
A clot was found in the deep venous system of the left leg. As you
can see the vein is distended with echogenic material and cannot be
compressed. 
A vena cava filter was placed.
A decision was made to remove the clots surgically.
The
patient was placed on cardiopulmonary bypass after a sternal
splitting incision.
The right ventricle and right atrium are clearly dilated.
Cannulas were placed in the right atrium and aorta to bypass the
heart. 
The space around the heart was packed with ice to lower its
metabolic needs. 
Pulmonary artery embolectomies are technically difficult. These
were the clots that were removed from the right pulmonary artery.
The entire
process required three hours on bypass.
A post-op echocardiogram showed that the right ventricle had
decreased markedly in size implying much lower pressure in the
pulmonary circuit. 
Case Assessment
This was a 30 year old male who was in good health until 2 weeks
prior to admission. He presented with dyspnea on exertion that was
temporally related to a prolonged automobile trip. He presents with
dyspnea on exertion, dull substernal chest pain, pulmon ary
hypertension, and hypoxemia.
Most patients with deep venous thrombosis and a pulmonary embolus have an underlying predisposition to thrombosis. A retrospective review of this patients family history revealed a number of close relative who have suffered unexplained episodes of deep venous thrombosis and the patient is be lieved to have a familial clotting disorder. The prolonged car trip alone was not felt to be an adequate explanation this patients DVT.
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