Author + information
- Received August 11, 2016
- Revision received September 15, 2016
- Accepted September 16, 2016
- Published online January 2, 2017.
- Deepali Nivas Tukaye, MBBS, PhDa,∗ (, )
- Michael McDaniel, MDa,
- Henry Liberman, MDa,
- Yelena Burkin, MDb and
- Wissam Jaber, MDa
- aDivision of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia
- bDivision of Internal Medicine, Department of Medicine, Emory University, Atlanta, Georgia
- ↵∗Reprint requests and correspondence:
Dr. Deepali Nivas Tukaye, Emory University, Division of Cardiology, 101 Woodruff Circle, 319 WMB, Atlanta, Georgia 30322.
A 66-year-old African-American woman with no significant medical history presented with a 2-day history of worsening exertional dyspnea with minimal activity. Pulmonary embolus (PE) was suspected on the basis of clinical presentation and elevated D-dimer levels in absence of other clear explanation for her symptoms. Computed tomography of the chest revealed extensive, acute bilateral pulmonary embolus with significant clot burden in the right main pulmonary artery (PA). There was evidence of right heart strain with right ventricular (RV) dilation (elevated troponin [0.39 ng/ml] and brain natriuretic peptide [187 pg/ml]; right ventricle/left ventricle ratio 1.17 on computed tomography). Transthoracic echocardiography confirmed moderate RV dilation and systolic dysfunction. The patient’s estimated RV systolic pressure was 71 mm Hg. She was hemodynamically stable at admission, with normal blood pressure and heart rate and oxygen saturation >90% on room air. Given her hemodynamic stability and on the basis of the patient’s own preference, she was started on intravenous heparin and conservative management. Over the next 72 h, her symptoms did not improve, and she perceived dyspnea at rest. Repeat transthoracic echocardiography revealed persistent RV dilation and systolic dysfunction, with an estimated RV systolic pressure of 90 mm Hg. Because of persistent significant symptoms and severe pulmonary hypertension, she underwent percutaneous aspiration and mechanical pulmonary embolectomy from her right PA and segmental (middle and lower) arteries. Pre-procedural pulmonary angiography revealed absent pulmonary arterial flow to the right middle and lower lobes (Figure 1A). Her mean PA pressure post-procedure was 45 mm Hg. The procedure was performed using the FlowTriever (Figure 1B) retrieval and aspiration system (INARI Medical, Irvine, California). A significant amount of thrombus was aspirated (Figure 1C) after 3 passes in different lower and middle lobe segmental branches, with establishment of normal arterial flow to the right middle and lower pulmonary lobes (Figure 1D). The patient’s mean PA pressure immediately post-embolectomy was 33 mm Hg. She had a noticeable improvement in her dyspnea and improvement in oxygen saturation. Twenty hours post-procedure, transthoracic echocardiography revealed a decrease in RV dilation to mild from moderate, a reduction in RV dysfunction to mild from moderate, and an estimated RV systolic pressure of 45 mm Hg, a decrease from 90 mm Hg. The patient was able to ambulate with minimal dyspnea. She was switched to oral apixaban for management of pulmonary embolus and discharged 24 h post-thrombectomy.
Dr. Jaber is principal investigator for FLARE (FlowTriever Pulmonary Embolectomy Clinical Study) at Emory University. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 11, 2016.
- Revision received September 15, 2016.
- Accepted September 16, 2016.
- American College of Cardiology Foundation