Percutaneous Rotational Pulmonary Thrombectomy
A 77-year-old woman was admitted to the emergency department 4 hours after the sudden onset of chest pain, palpitations, and dyspnea. Her blood pressure was 60/40 mm Hg. An electrocardiogram showed sinus tachycardia, right bundle-branch block, S1Q3T3 pattern, and ST-segment elevation in the inferior leads that mimicked myocardial infarction (Panel A, arrows). Transthoracic echocardiography was performed at the bedside; the right ventricle chamber seemed larger than the left ventricle chamber, with severe tricuspid regurgitation. The patient was brought to the catheter laboratory for evaluation, and her coronary arteries were found to be normal. She received a diagnosis of pulmonary emboli with bilateral extensive thrombi in the proximal pulmonary arteries (Panels B and C, arrows). A 6-French pigtail catheter was advanced into the embolus site and then rotated back to the desired position (Video). Tissue plasminogen activator was subsequently delivered directly into the clot through the pigtail catheter. The patient was given norepinephrine to stabilize her hemodynamic status and then transferred to the intensive care unit. Tissue plasminogen activator was administered over the next 90 minutes, and therapy with unfractionated heparin was initiated. Repeat transthoracic echocardiography performed at the bedside revealed impaired right ventricular function, dilatation of the right chamber of the heart with severe tricuspid regurgitation, elevated systolic pressure of the pulmonary artery (45 mm Hg), and preserved left ventricular function. The next day, the patient had a cardiac arrest as a result of cardiogenic shock due to right ventricular failure and died despite resuscitative efforts.