Acute improvement in right ventricular function after treatment of presumed massive pulmonary embolism with thrombolytics
A 57-year-old woman with a history of Non-Hodgkin's Lymphoma thought to be in remission presented with the acute onset of dyspnea, fever, and hemoptysis. Admission chest imaging and bronchoscopy were diagnostic for diffuse alveolar hemorrhage secondary to adenovirus pneumonia. An admission transthoracic echocardiogram was normal, including normal biventricular chamber size and function. Chemical thromboembolic prophylaxis was held on hospital day (HD) four given her life-threatening pulmonary bleeding; sequential compression devices were applied until HD 12, when prophylactic heparin was resumed. With ventilatory support, parenteral steroids and eventual diuresis, the patient's pulmonary status improved over the subsequent two weeks.\nOn intensive care unit Day 15 (HD 17), the patient developed the acute onset of rapidly increasing vasopressor requirements, refractory hypoxia, and tachycardia despite improvement in her airway pressures and the appearance of her chest imaging. A repeat bedside transthoracic echocardiogram revealed normal left ventricular function, but severe RV dilation with qualitative and quantitative evidence of RV hypokinesis (). Chest imaging to confirm the presence of a pulmonary embolism could not be obtained given the patient's reduced glomerular filtration rate and hemodynamic instability.\nGiven the acute development of signs, symptoms and imaging changes consistent with an acute, massive pulmonary embolism, the treatment team administered tissue plasminogen activator 10 mg given as a bolus, followed by 90 mg given as an infusion over the subsequent two hours. At the completion of the infusion, the patient's vasopressor requirement decreased from norepinephrine 20 mcg/min and vasopressin 0.04 units/min to being off all vasopressors, her oxygen requirement decreased from a fraction of inspired oxygen of 100% to 40%, and her heart rate decreased from 130 to 90 beats/min. Repeat transthoracic echocardiogram the following day showed mild RV dilation, resolution of RV dysfunction (), and a decrease in estimated pulmonary vascular resistance.