Right ventricular thrombus in case of atrial septal defect with massive pulmonary embolism: A diagnostic dilemma
A 55-year-old woman presented to the emergency services with a history of breathlessness and altered sensorium of 1 day duration. Other than a history of alcohol and tobacco abuse, her history was noncontributory. On examination, breathing was labored, respiratory rate was 24/min, heart rate was 110/min, and on pulse oximeter, saturation was 88%. She had no focal neurological deficits. The electrocardiography showed deep S-wave in lead I with inverted T-waves in lead III with right ventricular strain suggestive of probably pulmonary embolism, and chest X-ray showed cardiomegaly with right ventricular apex dilated right atrium (RA), ventricle, and pulmonary artery (PA). Arterial blood gas revealed a pH – 7.24, PO 2 – 58 mm of Hg with 6 L of oxygen, PCO 2 – 66.4 mm of Hg, and HCO 3 – 24.7 suggestive of type II respiratory failure. Biochemical investigations revealed elevated D-dimer, normal cardiac bio-markers, hypoalbuminemia, thrombocytopenia, and negative thrombophilia work-up. Liver enzymes were within normal limits. Lower limb venous Doppler did not reveal any thrombus. Ultrasound abdomen showed coarse echo texture of liver with no evidence of portal hypertension or cirrhosis. Transthoracic echocardiogram showed dilated RA and right ventricle (RV), RV thrombus, moderate RV dysfunction, pulmonary hypertension (right ventricular systolic pressure [RVSP]-58 mm of Hg), no regional wall motion abnormalities, and normal left ventricular function. Computed tomography (CT) pulmonary angiogram revealed thrombus in the main pulmonary artery (MPA) extending into the left pulmonary artery (LPA) with multiple pulmonary infarcts. CT brain was normal. The patient was started on anticoagulation and titrated to an international normalized ratio (INR) of 2-3 preoperatively. She was considered unsuitable for thrombolysis in view of altered mental status and alcoholic liver disease. She developed worsening respiratory failure and was intubated a week after admission. After a multidisciplinary review, the decision was taken to go ahead with surgical embolectomy.
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