A very evident pulmonary thrombus

ABSTRACT

Clinical case Female patient, 78 years-old, that complained of epigastric pain and intense fatigue for a week. While waiting in the urgency department, she became hypotensive, with refractory shock. Electrocardiogram showed sinus rhythm, 90 bpm, De novo right bundle block and infraST in the right precordial leads. The echocardiogram showed a dilated right ventricle (ratio RV/LV>1), with depressed function and major tricuspid regurgitation, RV/RA gradient of at least 55 mmHg. Left ventricle presented "D-shape", preserved function and no segmental kinetic changes. The pulmonary artery was dilated and a serpentiform mass was visible, protruding through the pulmonary valve;similar masses were also visible in its branches. The diagnosis of pulmonary embolism (PE) was assumed and fibrinolysis was started, given there were no contra-indications. One year before, she had an intermediate-risk PE in the context of COVID-19, with a similar echocardiographic presentation. She recovered RV function in the following months and stopped anticoagulation 3 months after that episode. Discussion(s) PE can present with varying degrees of severity. Bedside echocardiography can be of major help in its diagnosis, especially in critical patients. The visualization of a thrombus in the pulmonary artery is rare, particularly in transthoracic echocardiogram. Echocardiogram is also useful for risk stratification and prognostic evaluation. This patient developed obstructive shock due to massive PE and the fibrinolytic treatment was paramount for her survival. A good echocardiogram helped in the differential diagnosis and enabled the Cardiologist to assist the patient in the best way.