CHEST Guidelines-A-70-Year-Old-Man-With-Worsening-Dyspnea-After-an-

A-70-Year-Old-Man-With-Worsening-Dyspnea-After-an-

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A 70-year-old man was hospitalized after experiencing worsening dyspnea following an ankle fracture. His shortness of breath developed three days prior to admission, alongside dizziness. Despite having no significant past medical history, he was diagnosed with a right common femoral deep vein thrombosis (DVT) and a massive pulmonary embolism (PE) after displaying signs of sinus tachycardia, hypoxia, and hypotension soon after starting treatment with unfractionated heparin. A prompt point-of-care ultrasound revealed severe right ventricular dysfunction, with evidence of a clot in transit that suggested a massive PE.<br /><br />The patient underwent urgent surgical embolectomy. During surgery, the doctors removed thrombi from the right atrium and the pulmonary arteries. However, as the patient was being weaned off cardiopulmonary bypass, his condition became unstable, necessitating the temporary use of a right ventricular assist device (RVAD) to support his heart function. The patient's right ventricular function improved over time, and he was gradually weaned off inotropic support, with the RVAD being removed on the 14th postoperative day. He was discharged to rehabilitation one month post-hospitalization.<br /><br />The presence of free-floating right heart thrombi (FFRHT) is known to predict poor outcomes, with high mortality rates if not promptly treated. In this case, early diagnosis was achieved using bedside echocardiography, demonstrating its crucial role, particularly in cases of undifferentiated shock. The condition was managed successfully through surgical intervention due to the rapid identification and treatment of the thrombi. This case underscores the importance of timely echocardiography in managing massive PE and the significant role of surgical embolectomy, especially in hemodynamically unstable patients.

Keywords

pulmonary embolism

deep vein thrombosis

right ventricular dysfunction

surgical embolectomy

right ventricular assist device

echocardiography

thrombi removal

cardiopulmonary bypass

hemodynamic instability

free-floating right heart thrombi