A 62-year-old woman status post left hip replacement approximately two months prior to presentation arrived in the ED with chest pain and SOB. The CT scan confirmed pulmonary embolus involving the right PA. Ultrasound confirmed extensive DVT in the left lower extremity. She was neurologically and hemodynamically stable with normal BP and HR with oxygen saturation >92% on 2 L NC. Troponin was mildly abnormal.
What would be your next step in managing this patient?
The correct answer is: C. Surgical embolectomy.
The pre-operative coronary angiography showed no significant coronary artery disease. This patient underwent surgical embolectomy and closure of PFO. A large thrombus was removed from PA. The patient did well and is thriving at the six-month follow-up. A recent editorial1 highlights surgical advantages of surgical pulmonary embolectomy although this case is somewhat unique with the presence of active thrombus in transit through a PFO.
Surgical Specimen of bi-atrial clot:
Goldhaber, Samuel MD. Surgical Pulmonary Embolectomy: The Resurrection of an Almost Discarded Operation. Texas Heart Institute Journal 2013;40:5-8.