Optimal Treatment of Submassive Pulmonary Embolism
A 56-year-old morbidly obese man presents to the emergency room with a week-long history of progressive dyspnea, pleuritic chest pain, shoulder pain, fatigue, and restlessness. His symptoms occurred abruptly. He has a history of gastric bypass surgery two years prior to current admission and has lost 40 kg. Despite his history, he weighs 140 kg, blood pressure is 125/86 mm Hg, heart rate is 112 per minute at rest, respiratory rate is 24 per minute, and he is afebrile. He is apprehensive and uncomfortable and becomes significantly dyspneic, even when talking. His jugular venous pressure is measured at 12 cm H2O; there is a 1/6 systolic regurgitant murmur at the left lower sternal border that increases with inspiration, accentuated P2 and a right ventricular heave. There is 2+ pitting edema, 1+ palpable pedal pulses, skin hyperpigmentation, and evidence of chronic venous insufficiency. Computed tomography angiography (CTA) of the pulmonary arteries is shown in Figure 1. His pretreatment echocardiogram is shown in Figure 2. In addition, the relative size of the cardiac chambers on CTA is shown in Figure 3. His D-dimer is 10.5 mcg/mL, troponin I is 2.2 ng/mL and pro-brain natriuretic peptide (proBNP) is 1,642 pg/mL.
Which of the following treatment strategies will lead to all of the following: rapid reduction of pulmonary hypertension and improvement in symptoms, shortest hospitalization time, probable improvement in survival, lowest cost, and very low incidence of bleeding?