Development of massive pulmonary embolism during echocardiographic imaging: A case report

RATIONALE: Pulmonary embolism (PE) is a common diagnostic consideration for patients who present to the emergency department (ED) with chest pain, dyspnea, or both. In addition, PE has a very high mortality in patients who are hemodynamically unstable. An electrocardiography, bedside transthoracic echocardiogram, and computed tomography pulmonary angiogram are usually performed to confirm the diagnosis. PATIENT CONCERNS: A 53-year-old man was admitted to the cardiology clinic with complaints of dyspnea, chest pain, and general weakness after walking. He had a history of hypertension and smoking. DIAGNOSIS: During synchronous recording of echocardiographic images, a large mobile thrombus detached from the right atrium, and first embolized to the right ventricle and then to the main pulmonary artery from the right heart chambers. Soon after, shortness of breath developed which clinically worsened the patient. Transthoracic echocardiogram which demonstrated the thrombus in the pulmonary artery or right heart chambers was suspected of causing acute massive PE. INTERVENTIONS: The patient was transferred to Critical Care Unit for monitoring; 100 mg of alteplase was initiated immediately and alleviated the hemodynamic instability within 2 hours of intravenous administration. OUTCOMES: To the best of our knowledge, this is the first synchronous echocardiographic recording showing the embolization of a thrombus from the right atrium, first to the right ventricle and then to the main pulmonary artery. LESSONS: Transthoracic echocardiography provides a safe, rapid, and noninvasive diagnostic tool for evaluation of suspected massive PE. Thrombolytic therapy is useful for treating acute massive PE that leads to hemodynamic instability.