Right atrial thrombus and massive pulmonary embolism refractory to thrombolytic therapy: A case report

INTRODUCTION: Unsuccessful thrombolysis in the setting of massive pulmonary embolism confers poor prognosis and the optimal management strategy is unknown. Options include re-thrombolysis and embolectomy. PRESENTATION OF CASE: A 32-year-old lady presented with massive pulmonary embolism accompanied by an intermittently-obstructive right atrial thrombus. Failure to improve with thrombolytic therapy prompted transfer to our cardiothoracic unit for emergency surgical embolectomy. The procedure and postoperative course were without complications and the patient made a complete recovery. DISCUSSION: Contemporary data has favoured thrombolytic therapies over surgical embolectomy as the initial management strategy in massive pulmonary embolism. This case is a timely reminder of the role that surgery retains in the management of these critically ill patients, particularly when cases are complicated. We illustrate the importance of rescue surgical embolectomy in the management of massive pulmonary embolism following unsuccessful thrombolysis. In addition, we briefly review other scenarios in the management of massive pulmonary embolism where lower threshold for surgical intervention is warranted. CONCLUSION: Although current data are insufficient to direct a high level of evidence-based care, this case report and others highlight the feasibility and safety of surgical embolectomy in complicated cases of massive pulmonary embolism.