title: Right Heart Transvalvular Embolus with High Risk Pulmonary Embolism in a Recently Hospitalized Patient: A Case Report of a Therapeutic Challenge.
abstract: Thrombus-in-transit is not uncommon in pulmonary embolism but Right Heart Transvalvular Embolus (RHTVE) complicating this is rare. A 54-year-old obese male with recent hospitalization presented with severe dyspnea and collapse. Initial investigations revealed elevated d-dimer and troponin. CTA showed saddle pulmonary embolus and bedside echocardiogram revealed right ventricular (RV) pressure overload and dilatation (RV > 41 mm), McConnell's sign, and mobile echodensity attached to tricuspid valve. Patient was immediately resuscitated and promptly transferred for surgical embolectomy under cardiopulmonary bypass. A long segment of embolus traversing through the tricuspid valve and extensive bilateral pulmonary artery embolus were removed. IVC filter was placed for a persistent right lower extremity DVT. Hypercoagulable work-up was negative. Patient continued to do well after discharge on Coumadin. Open embolectomy offers great promises where there is no consensus in optimal management approach in such patients. Bedside echocardiogram is vital in risk stratification and deciding choice of advanced PE treatment.
authors.affiliation: Department of Internal Medicine, Wyckoff Heights Medical Center, Brooklyn, NY 11237, USA.
authors.forename: Gyanendra Kumar
authors.initials: GK
authors.lastname: Acharya
authors.affiliation: Department of Internal Medicine, Wyckoff Heights Medical Center, Brooklyn, NY 11237, USA.
authors.forename: Ajibola Monsur
authors.initials: AM
authors.lastname: Adedayo
authors.affiliation: Division of Cardiology, Department of Internal Medicine, Wyckoff Heights Medical Center, Brooklyn, NY 11237, USA.
authors.forename: Hejmadi
authors.initials: H
authors.lastname: Prabhu
authors.affiliation: Department of Cardiothoracic Surgery, Lenox Hill Hospital, North Shore-Long Island Jewish Health System, New York, NY 10075, USA.
authors.forename: Derek R
authors.initials: DR
authors.lastname: Brinster
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Wyckoff Heights Medical Center, Brooklyn, NY 11237, USA.
authors.forename: Parvez
authors.initials: P
authors.lastname: Mir