Successful Embolectomy of a Migrated Thrombolytic Free-Floating Massive Thrombus Resulting in a Pulmonary Thromboembolism
A 74-year-old woman presented at our emergency room with sudden-onset dyspnea. Her blood pressure was 70/50 mmHg, and her heart rate was 140 beats/min at that time. The electrocardiogram showed sinus tachycardia and ST-T wave depression in leads V1 to V3. Chest computed tomography showed filling defects in the right ventricle (RV) and both pulmonary arteries (). Echocardiography was then performed immediately and showed a D-shaped left ventricular cavity with enlargement of the right atrium (RA) and RV. In addition, a free-floating and thread-like echogenic material attached to the tricuspid valve was observed (, ). Laboratory data showed normal white blood cell and platelet counts, the aspartate aminotransferase level was elevated to 210 IU/L (normal values: 13-33 IU/L), and the lactate dehydrogenase level was increased to 469 IU/L (normal values: 119-229 IU/L). In addition, both D-dimer (56 µg/mL, normal values: less than 0.5 µg/mL) and B-type natriuretic peptide (230 pg/mL, normal values: less than 99 pg/mL) were also elevated. Immediately, the recombinant tissue plasminogen activator (Actylase®, Boehringer Ingelheim, Ingelheim, Germany) 100 mg was intravenously received and followed by 18000 U per day unfractionated heparin infusion. After the administration of thrombolytic agents, no free-floating, rod-shaped materials were observed within the RA and RV, and only the thread-like echogenic material attached to the tricuspid valve was found to be improved (, ), but RV dysfunction persisted. However, the patient's blood pressure was not restored with inotropic agents, and cardiac arrest occurred. An emergency cardiopulmonary bypass was performed, including a right atriotomy; no FFTRH was identified in the RA or RV cavity, including the tricuspid valve (). However, the massive thrombus and FFTRH were extracted from the bilateral pulmonary arteries under direct vision using forceps inserted through a longitudinal incision in the main pulmonary artery (). The postoperative course of this patient was stable without recurred PTE.