Massive Right Ventricular and Pulmonary Artery Emboli In-Transit after Cardiac Surgery: Consideration of Non-Surgical Treatment

Background:Pulmonary embolism (PE) is a complication of open-heart surgery that accounts for 0.6% of all cases and its mortality rate varies from 50% to 100%. Here, we describe a case of right ventricular and pulmonary artery emboli in-transit. Case report: A 56-year-old female presented with complain of dyspnea and palpitation and history of recent coronary artery bypass graft (CABG) surgery. Edema of the right leg was noted. Trans-esophageal echocardiography (TEE) performed and revealed severe tricuspid regurgitation due to stucking clot in tricuspid valve. A large clot in right ventricle (RV) and right ventricle outflow tract (RVOT) with the size of 55 × 13mm was noted. There was also a clot with the size of 22 × 10mm in right pulmonary artery (RPA). Early in the ICU, patient received 10 units (18mg) of reteplase (IV) over 2 minutes and then 10 units was given with the rate of 1mg/hour after the first dose, with 30 minutes intervals. IV Heparin (18mg/Kg/h) was also co-administered with reteplase.There was no visible clot in RV and pulmonary artery in follow-up echocardiography. Patient transferred to CCU with stable hemodynamics and finally discharged with normal condition. Discussion: Surgery is an alternative in patients with massive PE but our patient had a prior cardiac surgery which re-operation had a high risk for her. Due to massive in-transient emboli of right heart and PA in our patient, we decided to proceed the treatment with reteplase. The patient was monitored carefully for hemodynamics and coagulation parameters and she was discharged without any systemic complication.