Vol.48 - Número 1, Enero/Marzo 2019 Imprimir sólo la columna central

Hemodynamically unstable pulmonary thromboembolism
in the postoperative period of abdominal surgery
JULIETA COCCO, LUIS KELLER, DANIEL ZANUTTINI
Instituto de Cardiología del Sanatorio Británico SA.
(2000) Rosario, Argentina.
E-mail
Recibido 27-NOV-2018 – ACEPTADO después de revisión el 26-DICIEMBRE-2018.
There are no conflicts of interest to disclose.

 

This case is about a 48-year-old man, with a history of type-2 diabetes, hypertension, on the seventh day of having been admitted into hospital because of postoperative period of duodenal pancreatectomy in intensive care unit, who presented a sudden episode of tachycardia associated to severe hypotension, peripheral hypoperfusion, hypoxemia, and hypercapnia with maladjustment to mechanical ventilation, refractory to the instated pharmacological treatment with vasopressors and expansion with crystalloids. Electrocardiogram was conducted, showing sinus rhythm, 100 bpm, QRS segment 100 ms, QT segment 440 ms, S1-Q3-T3 pattern and new complete bundle branch block.

The following differential diagnoses were proposed: sepsis, acute myocardial infarction and acute pulmonary thromboembolism [1]. Doppler echo was made, showing severe dilatation of right chambers, dyssynchronic septal parietal motility, right ventricular free wall akinesis with normal apical motility (McConnell’s sign), preserved left ventricular ejection fraction [2].

He was admitted into the hemodynamics lab with suspicion of acute pulmonary thromboembolism, for angiography and possible pulmonary artery thrombolysis [3]. During the procedure, he developed cardiorespiratory arrest from which he recovered. Right and left pulmonary arteries occlusion became evident, with no peripheral circulation secondary to thrombosis (Figure 1), so mechanical thrombolysis was made with pigtail catheter, attempting to break the thrombus and pharmacological thrombolysis in both pulmonary arteries with streptokinase 1,500,000 IU [4]. Rechanneling of pulmonary trunks became evident, as well as partial reperfusion of pulmonary arterial tree with subsequent hemodynamic stabilization (Figures 2 and 3). In the intensive care unit, he remained hemodynamically unstable, requiring high doses of inotropic agents and IV sodium heparin. He presented a new cardiorespiratory arrest, so advanced cardiopulmonary resuscitation maneuvers were applied unsuccessfully and he died.


Figure 1.


Figure 2.


Figure 3.

 

BIBLIOGRAPHY

  1. Tritschler T, Kraaijpoel N, Le Gal G, Wells PS. Venous thromboembolism: Advances in diagnosis and treatment. JAMA 2018; 320: 1583-94.
  2. Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Endorsed by the European Respiratory Society (ERS). Eur Heart J 2014; 35: 3033-73.
  3. Barco S, Konstantinides SV. Pulmonary embolism: Contemporary medical management and future perspectives. Ann Vasc Dis 2018; 11: 265-76.
  4. Porres-Aguilar M, Anaya-Ayala JE, Heresi GA, Rivera-Lebron BN. Pulmonary Embolism response teams: A novel approach for the care of complex patients with pulmonary embolism. Clin Appl Thromb Hemost 2018; doi:10.1177/1076029618812954.

Publication: March 2019



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