Not All That Is Clot Needs Busting!
A 42-year-old female patient with a medical history significant for type 2 diabetes mellitus presented to the hospital with a 1-week history of new-onset exertional dyspnea. Her vital signs were blood pressure of 118/72 mmHg, heart rate of 92 bpm, and O2 saturation of 98% (2L nasal cannula). The patient's initial physical exam was largely unremarkable, with the exception of jugular venous distention estimated at 12 cm of water. A chest X-ray was negative for any acute process. Computed tomography angiography (CTA) demonstrated central pulmonary emboli present in both pulmonary arteries as well as in sub-segmental branches of the right upper lobe, right middle lobe, and both lower lobes (Figure 1). The right ventricle/left ventricle ratio was calculated at 1.7. Transthoracic echocardiogram revealed a large, mobile right atrial (RA) thrombus measuring 4.3 x 2.2 cm (Figure 2A). In addition, there was significant right ventricular dysfunction and severely elevated pulmonary artery (PA) pressure >90 mmHg with normal left ventricular and left atrial size and function (Figure 2B). Troponin was <0.01.
What are the correct diagnosis and the most appropriate next step in this patient's treatment?