Low-Dose Thrombolysis in an Intermediate High-Risk Submassive Pulmonary Embolism With Right Atrial Thrombus: A Case Report

Abstract

BACKGROUND: Venous thromboembolism, encompassing pulmonary embolism (PE) and deep  vein thrombosis (DVT), is the third most common acute cardiovascular syndrome. It requires  prompt diagnosis and risk-based treatment strategies.  CASE: A 47-year-old male, 30-pack-year smoker who recently underwent open reduction and  internal fixation of the right femur presented with dyspnea. There was no hemodynamic instability.  Twelve-lead electrocardiogram showed sinus rhythm with incomplete right bundle-branch  block, and troponin was elevated. Chest x-ray showed dilated right descending pulmonary  artery. Two-dimensional echocardiogram revealed right atrial thrombus with right ventricular  dysfunction. Computed tomography of the pulmonary artery confirmed massive PE with infarct  on the posterobasal segment of the right lower lobe. Venous duplex scan of the lower extremities  showed an acute DVT of the right femoral vein, popliteal vein, and peroneal vein. Anticoagulation  was started. With a dilemma of a recent surgery in an intermediate high-risk submassive  PE, options other than guideline-recommended systemic thrombolysis were considered. A  multidisciplinary consensus recommended the administration of low-dose thrombolysis, which  later resulted to clinical improvement.  CONCLUSION: This is the first documented local case of successful resolution of a right  atrial thrombus with pulmonary thrombus and DVT using low-dose thrombolysis, without  complications of bleeding, in a patient with contraindications to thrombolysis. With more clinical  experience and studies of low-dose recombinant tissue plasminogen activator in this special  population, it can offer a promising treatment option.  KEYWORDS: pulmonary embolism, submassive, low-dose systemic thrombolysis,  contraindication for thrombolysis, alteplase, tPA, right atrial thrombus