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.