Introduction: Venous thromboembolic disease is the third, most frequent cardiovascular disorder and its most severe clinical presentation is the acute pulmonary embolism. Being caused by the obstruction of pulmonary arteries or their branches by thrombus arising from the venous system or, less often, from the right heart, the acute pulmonary embolism is associated with increased mortality and morbidity. Its manifestations can vary from total absence of symptoms to sudden death, dyspnoea being the most frequent symptom. Tachycardia is its commonest clinical sign.
Objectiv: The aim of this paper is presenting a oligo-symptomatic massive pulmonary embolism case with rapid evolution which complicated a huge right atrial thrombus thrombolised with metalyse.
Methods: A 59 years old hypertensive patient, with no antihypertensive treatment, presented to the emergency department for an episode of loss of consciousness in the previous days and high blood pressure values (BP 200/ 100mmHg). He was admitted to the hospital and underwent clinical, biological and echocardiographic evaluation.
The clinical exam revealed hemodynamic and pulmonary stability. ECG- important right ventricle changes. Lab tests showed positive HS troponin, high NT-proBNP (4667 pg/ml), positive Ddimers. The echocardiography disclosed enlarged right cavities,severe tricuspid regurgitation and severe pulmonary hypertension; contrast thoracic CT scan was performed in order to identify the etiology and showed bilateral massive pulmonary embolism and infarction of the superior lobe of the right lung. On repeated echo examination, a large mobile thrombus of 6.7/4 cm in the right atrium was observed. The patient was classified as being at high risk and emergency i.v. thrombolysis was decided. The procedure was performed under echo guidance and, during the 2 min bolus, the lysis of the thrombus in the right atrium was recorded. A transitory arteri-al hypotension episode occurred during thrombolysis, but was corrected with inotropes. The therapy was with continuous infusion of unfractioned heparin, followed by antivitaminK treatment with loading dose; the co-agulation parameters (aPTT, then INR) were closely monitored. The patient was discharge stable and anti-coagulant treatment was recommended for at least 6 months, with monthly INR check
Conclusions: Severe pulmonary embolism can be pa-ucisymptomatic, but his diagnosis should be kept in mind, in a patient with loss of consciousness and tho-rough cardiologic evaluation should be performed. In our case, in spite of the absence of suggestive signs and symptoms, CT scan revealed high risk massive pulmo-nary embolism; meanwhile, echocardiography identi-fied an other intracardiac thrombus requiring imme-diate management. The case proves the value of multi-modality imaging in emergency care and management decisions.