Question of the week
ACC Patient Case Quiz
- A 42 years old female with a medical history significant for type 2 diabetes mellitus
- Presented to the hospital with a 1-week history of new-onset exertional dyspnea.
- Vital signs: BP 118/72 mmHg, HR 92 bpm, and O2 saturation of 98% (2L nasal cannula).
-Initial physical exam: largely unremarkable, with the exception of jugular venous distention estimated at 12 cm of water.
- Chest X-ray: negative for any acute process.
- CTA: central pulmonary emboli present in both pulmonary arteries & in sub-segmental branches of the right upper lobe, right middle lobe, and both lower lobes (Figure 1).
- The right ventricle/left ventricle ratio was calculated at 1.7.
- Transthoracic echocardiogram: a large, mobile right atrial (RA) thrombus measuring 4.3 x 2.2 cm (Figure 2A).
- Significant right ventricular dysfunction and severely elevated pulmonary artery (PA) pressure >90 mmHg with normal left ventricular and left atrial size and function (Figure 2B).
- Troponin was <0.01.
What are the correct diagnosis and the most appropriate next step in this patient"s treatment?
A. Acute pulmonary embolism (PE); treat with urgent surgical embolectomy
B. Acute PE; treat with aspiration thrombectomy
C. Acute PE with clot in transit; treat with thrombolytic therapy
D. Acute on chronic PE; start anticoagulation and assess for pulmonary thromboendarterectomy after 3 months
E. Chronic thromboembolic pulmonary hypertension; transfer patient to tertiary facility for urgent thromboendarterectomy