Methods (Differential Diagnosis, Investigations, and Treatment)
Initial chest CT revealed multiple filling defects in the distal main pulmonary artery, descending and upper lobar arteries, extending into the lobar and segmental arteries, with signs of right ventricular strain, evidenced by the dilatation of the main pulmonary artery (3.3 cm) and flattening of the interventricular septum toward the left ventricular cavity (Figure 1). A Doppler ultrasound of the lower limbs showed a bilateral deep vein thrombus. Echocardiography conducted upon admission identified a moderately dilated right ventricle with moderately reduced function, along with a mobile thrombus attached to the mid-right interventricular septal wall, severe pulmonary hypertension (RVSP 60 mm Hg), and evidence of RV pressure overload (Figure 2). Further RV strain analysis confirmed impaired function, with global RV strain at -8.3%, RV free wall strain at -8.4%, and tricuspid annular plane systolic excursion at 1.3 cm (Figure 3).
The patient was initially managed with oxygen therapy and intravenous heparin infusion to target an aPTT value of 50, adjusted from a baseline of 25. This was later switched to therapeutic enoxaparin at 120 mg BID. On the second day, due to the presence of the RV thrombus, lack of clinical improvement, and increasing trends in Pro BNP (1549 to 2048), troponin T (37 to 99), and D-dimer (3.67 to 5.04), thrombolytic therapy with 50 mg alteplase administered intravenously over 2 hours was initiated, followed by a return to heparin infusion (Figure 4). The cardiothoracic team was consulted, and they recommended continuing anticoagulation without intervention. The patient was subsequently transferred to a tertiary care center for further management.