Clinical Case 06—A fatal dance: a case report of a pulmonary embolism with mobile right ventricular thrombus

We report a case of a 44-year-old woman with past medical history of dyslipidemia under atorvastatin, overweight and depression, that presented to the emergency department with a 1-month history of dyspnea. On physical examination, blood pressure was within normal range, however she was hypoxemic, needing oxygen via nasal cannula, and tachycardic. Pulmonary auscultation revealed basal crackles. Blood workup showed discrete leukocytosis, increased C-reactive protein, mild hypertransaminasemia and increased troponin and NT-proBNP levels. An EKG revealed sinus tachycardia with 123 beats per minute. A D-shaped left ventricle, an enlarged right ventricle and right heart mobile thrombus were observed in a transthoracic echocardiogram.

Scoring 2 points on simplified Wells’ Score and with a visible mobile right ventricular thrombus, pulmonary embolism was suspected and further confirmed by computed tomographic pulmonary angiography. Management: In the absence of hemodynamic instability this case fulfils criteria for intermediate-high risk pulmonary embolism. Therefore, anticoagulation with enoxaparin was started under strict electrocardiographic monitoring. Unfortunately, a day later the patient had a sudden cardiac arrest in asystole, with no recuperation after prolonged advanced life support and administration of rescue thrombolysis (alteplase 50mg).