Massive Pulmonary Embolism after Hip Surgery with a Mobile, Snake-Like Right Atrial Thrombus Successfully Treated with Open Heart Surgery

Cen al B inging Excellence in Open Access   Jou nal o Ca diology & Clinical Resea ch Ci e his a icle: Khan JA, Hau alah i JE, Lau ikka JO (2017) Massi e Pulmona y Embolism a e Hip Su ge y wi h a Mobile, Snake-Like Righ A ial Th ombus Success ully T ea ed wi h Open Hea Su ge y. J Ca diol Clin Res 5(5): 1113. *Co esponding au ho Jahangi A. Khan, Depa men o Ca dio-Tho acic Su ge y, Hea Hospi al, Tampe e Uni e si y Hospi al, PO BOX 2000, Tampe e, Finland, Tel: +358331165037; Fax: +358331165756; Email Submi ed: 27 June 2017 Accep ed: 20 July 2017 Published: 22 July 2017 Copy igh © 2017 Khan e al. OPEN ACCESS Keywo ds •Th ombosis •Pulmona y embolism •Ca diac su ge y •Embolec omy Case Repo Massi e Pulmona y Embolism a e Hip Su ge y wi h a Mobile, Snake-Like Righ A ial Th ombus Success ully T ea ed wi h Open Hea Su ge y Jahangi A. Khan*, Juha E. Hau alah i, and Ja i O. Lau ikka Depa men o Ca dio-Tho acic Su ge y, Hea Hospi al, Tampe e Uni e si y Hospi al, Finland Abs ac Su gical embolec omy o pulmona y embolism and in aca diac h ombus is a a e bu occasionally equi ed p ocedu e ha should be conside ed when an icoagula ion and/o h omboly ic he apy is con aindica ed o ailed. We desc ibe a pa ien wi h massi e pulmona y embolism and a la ge, mobile, snake-like h ombus in he igh a ium, as well as a pa en o amen o ale, ea ed success ully by su ge y. ABBREVIATIONS PFO: Pa en Fo amen O ale INTRODUCTION Massi e pulmona y embolism is a po en ially le hal condi ion. Besides suppo i e ca e, con en ional ea men consis s o sys emic an icoagula ion, h omboly ic he apy and, in selec ed cases, su ge y o pe cu aneous ca he e -based p ocedu es. Su gical embolec omy should be conside ed when h ombolysis is con aindica ed o ailed [1]. CASE PRESENTATION A 70-yea old man was e e ed o ou hospi al he 1s o No embe 2016 because o malaise, hypo ension, achyca dia, and a collapse. He had been ope a ed on o a le -sided hip ac u e ou days ea lie and had ecei ed ou ine low-molecula -weigh hepa in p ophylaxis pos ope a i ely. The pa ien was p e iously diagnosed wi h polysy emia e a and had i e mon hs ea lie unde gone an abdominope ineal esec ion o a g ade II dis al ec al ca cinoma wi h no known me as ases. In he eme gency depa men , he pa ien was awake and o ien ed, wi h ini ial blood p essu e o 92/53mmHg and a pulse a e o 110. The pulse oxime y showed 97% oxygen sa u a ion wi h 9L oxygen low and he ECG e ealed a new igh bundle b anch block. A e ial blood gas analysis showed a pH o 7.42, pO2 o 12.2kPa, pCO2 o 4.5kPa, and a base excess o -3.5mmol/L. Physical examina ion and ches x- ay we e inconclusi e. Ches compu ed omog aphy e ealed massi e bila e al pulmona y embolism in ol ing each pulmona y segmen wi h a saddle embolus in he bi u ca ion o he pulmona y a e y while ca diac ul asound examina ion showed enla ged igh -sided ca diac chambe s and a la ge, snake-like mobile h ombus in he igh a ium (Figu e 1). A deep enous h ombus was also de ec ed in he le leg a he popli eal le el. An icoagula ion he apy was conside ed insu icien and h omboly ic he apy con aindica ed due o ecen su ge y and he mobile a ial h ombus. Su gical embolec omy was chosen as he ea men cou se a e mul idisciplina y discussion. The ope a ion consis ed o median s e no omy, no mo he mic pe usion wi h bica al cannula ion, ao ic c oss- clamping and ca dioplegic a es , embolec omy om he igh a ium, pulmona y unk, and bo h pulmona y a e ies, as well as closu e o he pa en o amen o ale (PFO) disco e ed du ing he ope a ion. The h ombus was pa ially disloca ed subph enically by he in e io ein cannula bu was lushed in o he ope a ional ield by loosening he ca al sna e. I was suspec ed bu could no hus be con i med ha he h ombus had been apped in he sizeable PFO. The incision in he pulmona y unk was con inued in o he le pulmona y a e y and he igh pulmona y a e y Cen al B inging Excellence in Open Access   Khan e al. (2017) Email: 2/3 J Ca diol Clin Res 5(5): 1113 (2017) was opened sepa a ely be ween he ao a and he supe io ena ca a. The h ombus (Figu e 2) was e ac ed using suc ion, o ceps, oga y ca he e s, and gen le lung manipula ion. The pos ope a i e cou se was une en ul. The pa ien was e e ed o e ia y ca e nine days a e su ge y and has eco e ed as usual he ea e . Follow-up ches compu ed omog aphy wo mon hs la e showed no complica ions o abno mali ies. DISCUSSION Pos ope a i e h ombo-embolic complica ions a e a signi ican cause o mo bidi y. In high- isk pa ien s - as he p esen case - addi ional p ophylac ic measu es, such as highe -dose hepa in p esc ip ion and/o he use o comp essi e s ockings, should be conside ed. In addi ion o he isk o dislodgemen in o he pulmona y ci cula ion, a igh a ial h ombus may cause pa adoxical embolism when p esen ing oge he wi h a PFO. A snake-like, highly mobile h ombus may sugges pa ial en apmen wi hin he PFO. In his se ing, an icoagula ion and/o h ombolysis he apy ca ies an exceedingly high isk o emboliza ion which, especially i associa ed wi h massi e pulmona y embolism, may p o e a al. Fu he mo e, h omboly ic he apy may cause in a-c anial hemo hage when adminis e ed wi h concomi an silen ce eb al emboli and he isk o pa adoxical embolus inc eases wi h ele a ed igh -sided p essu es associa ed wi h pulmona y embolism. Su gical embolec omy is a ela i ely easy p ocedu e allowing h ombec omy om ca diac chambe s and pulmona y a e ies as well as simul aneous closu e o a PFO i p esen . Embolec omy om he pulmona y a e ies may be pe o med unde pe usion wi hou a es ing he hea [2]. Howe e , i h ombus is p esen in he igh a ium and opening o he igh a ium is con empla ed, especially when a PFO is p esen / suspec ed, we sugges ao ic c oss-clamping and a es ing he hea o a oid sys emic emboliza ion. This allows be e con ol and yields he possibili y o en e ing he le a ium i a pa o he h ombus needs o be eco e ed. Bo h ib inoly ic he apy and pe cu aneous ea men ha e been desc ibed in a simila se ing [3,4]. The au ho s a gue ha hough success wi h hese echniques is possible, he isk o ca as ophic complica ions is ob ious and ha when no con aindica ion o su ge y exis s, hese pa ien s should be ope a ed on o a leas ea ed in a cen e wi h su gical backup. Figu e 1 A) Ches compu ed omog aphy showing a saddle embolus in he bi u ca ion o he pulmona y a e y. B) A la ge, mobile, and snake-like h ombus in he igh a ium in echoca diog aphy. Figu e 2 A) Th ombus e ie ed om he igh a ium. B) Emboli e ie ed om he main pulmona y a e y (middle), le pulmona y a e y (bo om), and igh pulmona y a e y ( op). Cen al B inging Excellence in Open Access   Khan e al. (2017) Email: 3/3 J Ca diol Clin Res 5(5): 1113 (2017) Khan JA, Hau alah i JE, Lau ikka JO (2017) Massi e Pulmona y Embolism a e Hip Su ge y wi h a Mobile, Snake-Like Righ A ial Th ombus Success ully T ea ed wi h Open Hea Su ge y. J Ca diol Clin Res 5(5): 1113. Ci e his a icle REFERENCES 1. Kons an inides S, To bicki A, Agnelli G, Danchin N, Fi zmau ice D, Galié, N e al. 2014 ESC Guidelines on he diagnosis and managemen o acu e pulmona y embolism. Eu Hea J. 2014; 35: 3033–3073. 2. Leacche M, Unic D, Goldhabe SZ, Rawn JD, A anki SF, Coupe GS, e al. Mode n su gical ea men o massi e pulmona y embolism: Resul s in 47 consecu i e pa ien s a e apid diagnosis and agg essi e su gical app oach. J Tho ac Ca dio asc Su g. 2005; 129: 1018–1023. 3. Sokmen G, Sokmen A, Al un B. 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