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An 84 year old man with chronic bronchiectasis was referred by a family doctor following a three day period of dyspnoea and exercise related central chest pain. On the day of admission he had dizzy spells and a short episode of syncope lasting a couple of minutes. On admission he had sinus tachycardia (115 beats/min). Heart sounds were dual with no additional murmurs and jugular venous pressure was elevated. On chest auscultation, expiratory wheeze was audible throughout lung fields but there were no crepitations. ECG showed right bundle branch block with left anterior fascicular block. Transthoracic echocardiogram performed in the emergency unit showed normal left ventricular size with preserved systolic function. The right ventricle was dilated with moderate to severely impaired systolic function. There was mild tricuspid regurgitation with the right ventricular systolic pressure estimated at 40 mm Hg.
There was a large coiled thrombus within the right ventricular (RV) cavity attached to the pulmonary valve (PV), (panels A and B below). The thrombus was highly mobile and was prolapsing through the pulmonary valve into the pulmonary artery. The thrombus dimensions were: width 1.0 cm, length 7.6 cm. The patient received immediate thrombolytic treatment using recombinant tissue plasminogen activator (r-tPA) 20 units intravenously at 30 minute intervals, and both symptoms and pulse oximetry improved initially. However, after two hours the patient again became symptomatic with pronounced hypoxia and intermittent systemic hypotension. At that time an intravenous infusion of streptokinase was recommended, 50 000 units per hour over a 24 hour period. The patient made a slow but uneventful recovery. Transthoracic echocardiogram repeated the next day showed no signs of thrombus (panel C) and improved right ventricular systolic function. Warfarin treatment was initiated and the patient was discharged home after nine days. At one year follow up, the patient is symptom-free with no episodes of recurrent pulmonary embolism.
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