Abstract Introduction Catheter-directed mechanical thrombectomy is increasingly used for intermediate- and high-risk pulmonary embolism (PE) with right ventricular (RV) strain. While generally safe(1), rare complications such as RV free-wall rupture can be rapidly fatal. Early detection through hemodynamic and echocardiographic monitoring is critical in recognizing such a complication. Case Summary A 62-year-old woman presented with acute dyspnea. Workup showed rising troponin and elevated D-dimer. CT angiography demonstrated a saddle PE with RV strain, and transthoracic echocardiography (TTE) revealed a severely dilated RV. The patient underwent thrombectomy, removing approximately 20 cm of thrombus. Oxygenation improved immediately (from 92% on 10 L face mask to 97% on room air), and she initially remained stable. Within hours, she developed progressive hypotension, requiring multiple vasopressors. Point-of-care ultrasound revealed a new large pericardial effusion absent on initial echo, concerning for cardiac rupture with tamponade physiology. Before a pericardial window could be performed, the patient suffered two cardiac arrests (2 min and 10 min) with return of spontaneous circulation but remained in refractory shock on four pressors. Repeat echocardiography showed complete resolution of the effusion, suggesting mobilization of effusion into the mediastinum. ECMO transfer was declined due to instability, and the patient ultimately died. Findings were most consistent with RV free-wall rupture following thrombectomy. Conclusion Submassive PE with RV strain carries significant mortality, reported up to 5 to 25%(2). Mechanical thrombectomy offers rapid reduction in clot burden, improved oxygenation, and a reduced ICU stay, often achieving faster stabilization than systemic therapy. However, as this case illustrates, severe complications such as RV wall rupture and cardiac tamponade, though rare, can be catastrophic. The combination of catheter manipulation within a high-pressure RV and sudden afterload reduction may precipitate rupture. It’s important that even patients who appear clinically stable after thrombectomy should undergo close post-procedural monitoring with repeat echocardiographic and hemodynamic assessment, including possible right heart catheterization, to detect evolving structural complications early. This abstract is funded by: None
Taha et al. (Fri,) studied this question.