Case Presentation

Gwyneth McNeill, DO Cardiovascular Disease Fellow- PGY5

Lankenau Medical Center

Case • HPI: 72 year old female presents with 2 weeks of

progressive dyspnea on exertion, now short of breath at rest.

• No chest discomfort, pre-syncope, syncope, palpitations, lower extremity edema or swelling

• Had seen oncologist earlier that week for her multiple myeloma. Noted to have SaO2 of 93%

• Recent work-up for exertional chest pain at outside hospital – Transthoracic echocardiogram: LV normal size and function,

EF 67%, RV normal size and function – Pharmacologic Nuclear Stress: Moderate Fixed perfusion

defect in LAD territory

• PMHx: – IgG Kappa multiple myeloma diagnosed in 2008, underwent stem cell

transplant in 2012, progressed and currently on Carfilzomib and Decadron

– PE and DVT in 2011 following Revilimid treatment with “brief” course of anticoagulation

– DM with A1C of 8.2 – CKD (baseline Cr 1.2) – Hypothyroidism – History of C Diff, VRE infections

• SHx: no pertinent • FHx:

– Mother: deceased, AAA – Father: stroke – Brother: MI at age 87

• Social: Former tobacco 1.5 pack years in college, rare EtOH, never drugs

• Home Medications: – Aspirin 81 mg daily – Amlodipine 5 mg daily – Losartan 100 mg daily – Levothyroxine 200 mcg daily – SQ Insulin – Rosuvastatin 40 mg nightly – Gabapentin 100 mg daily – Lamotrigine 100 mg daily – Propranolol 120 mg daily

• Allergies: NKDA

In the Emergency Room

• BP 103/56 HR 118 RR 21 SaO2 90% room air • General: Mild distress • Neck: No JVD • CV: Tachycardic, regular • Pulm: Tachypnea, CTAB • Abdominal: Soft, non-tender, no distention • MSK: No edema • Neuro: AAOx3 • Skin: warm and dry

Presenter

Presentation Notes

This is her ECG on presentation. As you can see it shows sinus tachycardia with a right bundle branch block. She did have a prior ECG in our system from several years ago and the right bundle is new this admission

Labs

• Na 139 • K 3.7 • Cl 107 • CO2 14 • BUN 22 • Cr 2.7 • Glucose 405 • Lactate 5.0 • Troponin 0.19

• WBC 11.4 • Hgb 10.7 • Hct 33.0 • Platelets 141 • INR 1.2 • PT 15 • PTT 31

Presenter

Presentation Notes

This is a transthoracic apical four chamber. You can see the left ventricular cavity is small and hyperdynamic with flattening of the intraventricular septum consistent with right ventricular pressure and volume overload. The RV is severely dilated with severely reduced systolic function, however, the apex is hyperdynamic which is consistent the McConnell’s sign.

Presenter

Presentation Notes

These next two images are parasternal long and short axis views. They again demonstrate the hyperdynamic LV with flattening of the septum consistent with RV pressure and volume overload.

Presenter

Presentation Notes

These next images show her tricuspid regurgitation and RVSP of 46 mmHg plus right atrial pressure. At this point given her history, presenting symptoms, echo findings, and inability to get a CTA due to CrCl the decision was made to proceed directly to the cath lab for pulmonary angiography.

Presenter

Presentation Notes

These two images demonstrate significant clot burden in the left and right pulmonary arteries. During the study the patient became progressively unstable and with her RV failure the decision was made to proceed to mechanical thrombectomy using the Flowtriever device.

Presenter

Presentation Notes

Using a femoral approach the Flowtriever device was advanced to the pulmonary arteries and mechanical aspirations of large clot were performed. This is an image status post clot removal.

• During the procedure, a large clot piece was noted on the tip of Flowtriever cannula without being able to pull it out. Maintaining the negative suction, the clot was pulled down to iliac vein, and infra-renal IVC filter was placed

• Due to persistent hypotension and severe RV dysfunction, was made to proceed with RV mechanical support with right ventricular assist device (Proteck Duo)

• Patient also developed atrial fibrillation with rapid ventricular response during procedure and emergent cardioversion was performed

• The patient did have minor hemoptysis during the procedure thought to be due to reperfusion injury

• Also started on inhaled Epoprostenol • Patient transferred to CICU

Presenter

Presentation Notes

This is a transthoracic echocardiogram performed the following day. You can see the RVAD in the right sided structures. You can also see the RV size and function has significantly improved.

Hospital Stay

• Day 2 bedside hemodynamic wean successful. RV size and function improved on echocardiogram. Decision was made to decannulate right ventricular assist device.

• Continued to be hemodynamically stable • Transitioned to direct oral anticoagulant • Repeat echocardiogram as outpatient

Presenter

Presentation Notes

This is her echocardiogram from 1 month later. You can see the LV is no longer small or hyperdynamic. The RV size and function has normalized. The severity of the tricuspid regurgitation has been reduced to trace and her RVSP now is 23 mmHg plus right atrial pressure.

Take Home Points 1. Clinical decision making is key 2. Multidisciplinary approach to the case (ER, cardiology, cath lab

staff, pulmonary/critical care, house staff) 3. RVSP was elevated on presentation in this case, but not always in

obstructive shock 4. Patient can decompensate quickly, importance of hemodynamic

support at the right time 5. The important role the right ventricular assist device can play in

acute pulmonary embolism and RV failure 6. Importance of maintaining sinus rhythm during ongoing

hemodynamic embarrassment 7. Even with significant co-morbid conditions, acute RV failure from

PE can be successfully managed with good prognosis