case_images: PMC4100447_01
case_images: (a) The parasternal short axis view from echocardiography shows dilatation of the right ventricle (green line). (b) The CT-thorax with contrast filling defect in the right main pulmonary artery confirms the diagnosis of pulmonary embolism. (c) The fluoroscopy illustrates the placement of ultrasound-accelerated thrombolysis catheter in the right main pulmonary artery. (d) The improvement in right ventricular function after UAT (green asterisk).
case_images: CRIM2014-297951.001.jpg
case_images: PMC4100447_01_CRIM2014-297951.001.jpg
case_images: fig1
case_images: His echocardiography showed right ventricular enlargement with right-to-left ventricle ratio (RV/LV) greater than 1, dyskinesia of the RV (Figure 1), and right ventricle systolic pressure (RVSP) of 75 mmHg. The patient underwent UAT (1 mg/hr of alteplase was delivered for 12 hours via the catheter in Figure 1) in the right pulmonary artery and he continued to receive intravenous heparin; he was medically managed under Intensive Care Unit care.
case_images: PMC4100447_02
case_images: (a) The green triangle is located in the markedly dilated right ventricle. (b) The red arrows point at saddle emboli. (c) The echocardiogram shows improvement in the size of right ventricle. (d) The fluoroscopy confirms the placement of the UAT catheter in both main pulmonary arteries (blue arrows).
case_images: CRIM2014-297951.002.jpg
case_images: PMC4100447_02_CRIM2014-297951.002.jpg
case_images: fig2
case_images: He underwent CT-thorax which showed extensive thrombus in both distal main pulmonary arteries with small component of main pulmonary artery saddle thrombus (Figure 2). An emergent echocardiogram was obtained, which showed marked dilatation of the right ventricle, RV/LV > 1, and severe right ventricular global hypokinesis (Figure 2). Ten days later, a repeat transthoracic echocardiogram showed normal ejection fraction, RV/LV < 1, and minimal paradoxical septal motion (Figure 2) and RVSP of 62 mmHg.
case_images: PMC4100447_03
case_images: (a) The red square is in the right ventricle that is markedly dilated compared to left ventricle dimension. (b) The image shows the decrease in size of the right ventricle after the UAT (red square).
case_images: CRIM2014-297951.003.jpg
case_images: PMC4100447_03_CRIM2014-297951.003.jpg
case_images: fig3
case_images: The echocardiogram revealed preserved left ventricular ejection fraction, hypokinetic RV with RV/LV >1 and severe pulmonary hypertension (right ventricular systolic pressure of 73 mmHg) (Figure 3). Three days later, the echocardiogram showed left ventricular ejection fraction of 65%, without the evidence of right ventricular strain (RV/LV < 1) or elevated right ventricle systolic pressure (Figure 3).
case_images: PMC4100447_04
case_images: (a) The right ventricle is dilated and the septum is flattened (green asterisk). (b) The red arrows point at multiple bilateral emboli. (c) The image shows improvement in right ventricle dimension after the treatment.
case_images: CRIM2014-297951.004.jpg
case_images: PMC4100447_04_CRIM2014-297951.004.jpg
case_images: fig4
case_images: A CT-chest with contrast showed diffuse bilateral pulmonary emboli in the right and left main pulmonary arteries and straightening of the interventricular septum suggestive of right ventricular strain (Figure 4). The echocardiogram showed preserved ejection fraction, hypokinetic RV, mild pulmonary hypertension (RVSP of 49 mmHg), and RV/LV > 1 (Figure 4). Next day, a repeated echocardiography showed preserved ejection fraction with mildly depressed right ventricular function with RV/LV <1 (Figure 4) and RVSP of 40 mmHg.
case_images: PMC4100447_05
case_images: (a) The echocardiogram shows dilated right ventricle (green line). (b) The CT-scan shows an evidence of saddle emboli (red arrows). (c) There was a marked improvement in right ventricle size after the treatment (green line).
case_images: CRIM2014-297951.005.jpg
case_images: PMC4100447_05_CRIM2014-297951.005.jpg
case_images: fig5
case_images: A CT-scan of thorax with contrast revealed saddle pulmonary embolus of the right and left main pulmonary artery with extensive emboli (Figure 5). Based on these findings, a submassive PE was diagnosed (Figure 5). Two days later, repeated echocardiogram showed marked improvement in right ventricle function (RV/LV < 1) and right ventricle systolic pressure (45 mmHg) (Figure 5).