PE: A Clinical and Logistic Quandary

Case Presentation A 67-year-old man with no previous medical history presented to the emergency department with 5 days of insidious, progressive dyspnea and chest congestion. On physical examination, he was found to be tachycardic to 126 beats/min, borderline hypotensive with blood pressure of 95/50 mm Hg, and hypoxemic to 87% on 4 L of oxygen by nasal cannula. He underwent contrastenhanced chest computed tomogram that demonstrated a bilateral pulmonary embolism (PE) (Figure 1). Urgent bedside echocardiography demonstrated a severely dilated and hypokinetic right ventricle, interventricular septal flattening, and a serpiginous mobile mass (clot-in-transit) in the right atrium, prolapsing across the tricuspid valve with each cardiac cycle (Figure 2 and online-only Data Supplement Movie). The emergency department team discussed administering systemic fibrinolytic therapy, but also considered consulting Cardiothoracic Surgery for possible surgical pulmonary embolectomy and Interventional Cardiology for catheter-directed therapy. The emergency department attending physician decided to activate the hospital’s newly instituted multidisciplinary PE response team through the page operator. Within 30 minutes, a team consisting of representatives from Vascular Medicine, Interventional Cardiology, Cardiothoracic Surgery, Pulmonology, Echocardiography, and Radiology convened to evaluate the patient’s case and review the imaging studies.