(Circulation. 2000;102:2441.)
© 2000 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Acute Pulmonary Embolism
From the Division of Cardiology, University of Chicago Medical Center, Department of Medicine, Section of Cardiology, Chicago, Ill.
Correspondence to Roberto M. Lang, MD, University of Chicago Medical Center, 5841 S. Maryland Ave., MC5084, Chicago, IL 60637. E-mail rlang{at}medicine.bsd.uchicago.edu
A55-year-old man with
a history of paroxysmal atrial fibrillation, hypertension, and stroke
presented to the emergency room with the acute onset of
shortness of breath. He had previously been prescribed warfarin
therapy, which was self-discontinued 3 months before admission. A
baseline ECG made 6 months before admission showed normal sinus rhythm
with a heart rate of 80, an axis of -15°, and nonspecific T-wave
abnormalities (Figure 1A
).
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Physical examination at admission showed a respiratory rate of 35,
pulse of 130, and blood pressure of 130/90 mm Hg. The heart had a
regular rhythm with a normal S1, loud P2, 2+
right ventricular (RV) heave, and a 2/6
holosystolic murmur at the left lower sternal border. The left
calf was enlarged compared with the right, with increased warmth and
tenderness. The ECG on presentation depicted sinus
tachycardia with a heart rate of 133, a rightward axis
shift, the McGinn and White pattern
(S1Q3T3) associated with clockwise
rotation of the heart, an incomplete right bundle branch block, and
nonspecific ST segment and T-wave abnormalities (Figure 1B
). CT of the chest showed multiple bilateral low attenuation
filling defects in the lobar and segmental pulmonary arteries,
as well as a large fusiform filling defect in the main
pulmonary artery bifurcation consistent with
pulmonary emboli (Figure 2A). On
transthoracic ECG, the RV was severely dilated and
dysfunctional (Figure 2B) with diastolic flattening
of the interventricular septum consistent with RV
pressure overload (Figure 2C, arrowheads). Pulmonary
artery pressure was estimated at 50 mm Hg. On short axis view,
the main pulmonary artery was visualized with a large thrombus
at the bifurcation into the left and right pulmonary arteries
(Figure 2D).
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The patient received intravenous
thrombolytic therapy with tissue
plasminogen activator. He tolerated the
medication and showed a significant improvement in his
cardiopulmonary status. A repeat ECG on the second hospital day
revealed normal sinus rhythm with a heart rate of 96, an axis of
-5°, and nonspecific T-wave abnormalities (Figure 1C). The
incomplete right bundle branch block and the prominent
S1Q3T3 pattern were
no longer present. A follow-up ECG demonstrated resolution of the
RV dilatation and dysfunction and absence of the
pulmonary artery clot. The patient was treated with
intravenous heparin and discharged on warfarin without
complications.
Footnotes
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
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