Case Presentation:

An 88‐year‐old female with hypertension and no prior pulmonary disease presented with acute onset of dyspnea on exertion and chest discomfort. CT angiogram showed multiple acute pulmonary emboli as well as several chronic emboli involving the lobar branches of the pulmonary arteries. Troponin I was elevated, and it peaked at 1.33 ng/mL. EKG revealed no dynamic T‐wave changes. The patient was hemodynamically stable and unfradionated heparin drip was started. Transthoracic echocardiogram revealed markedly elevated PA pressure of 76 mm Hg, severely dilated RA, and severely dilated RV with severe tricuspid regurgitation. There was severe reduction in RV systolic function, but intact LV systolic function. A contrast study with agitated saline demonstrated a moderate right‐to‐lett shunt. Subsequent transesophageal echocardiogram showed a large atrial septal aneurysm with patent foramen ovale. The patient had a prior transthoracic echocardiogram from the previous year which did not show any right ventricular dysfunction or intracardiac shunt. The patient remained hemodynamically stable and was initialed on oral anticoagulation with warfarin with revaluation in 6 weeks for persistent PH and RV dysfunction that would show a high risk for further hemodynamic deterioration and for which pulmonary thromboendarterectomy may be considered.


The Treatment of submassive pulmonary embolism is challenging. Acutely, right ventricular dysfunction is considered a risk for subsequent hemodynamic instability. It is thought to be present in as much as half of patients with pulmonary embolism, who are normotensive at the time of presentation, and right heart failure is a common cause of death in these patients. Mortality rates are twice as much in this group when compared to those who present with normal RV function. Usually, pulmonary hypertension and RV dysfunction improves within 1 month; however, some patients will develop persistent PH and RV dysfunction, particularly those whose initial pulmonary artery pressure is greater than 50 mm Hg or whose age is more Than 70 years. Low‐molecular‐weight heparin or fondaparinux is considered appropriate; patients who have a high risk of early death may benefit from early thrombolysis, which has also been shown to hasten the recovery of right ventricular function and reduce the risk of chronic pulmonary hypertension. Our patient was not a candidate for thrombolysis because of an intracranial vascular anomaly. A complicating factor in this case was the presence of a new patent foramen ovale, which has been shown to substantially increase mortality in patients with acute PE.


The prompt recognition of the presence of right ventricular dysfunction in the absence of arterial hypotension is important in order to recognize potentially serious acute and long‐term hemodynamic complications. It is importanl to identify patients who will benefit from immediate thrombolysis as well as those who may require thromboendartereclomy later on.

Author Disclosure:

A. Silver, none; M. Wheaton, none; A. Shibani, none; D. Paje, none.