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).

(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.

(Figure 2)


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


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