Bilateral Pulmonary Embolism Masked by New-Onset Atrial Fibrillation with Rapid Ventricular Rate: The Role of Mechanical Thrombectomy

Patient: Male, 70-year-old Final Diagnosis: Atrial fibrillation • pulmonary embolism Symptoms: Dyspnea Medication: — Clinical Procedure: — Specialty: Cardiology OBJECTIVE: Unusual clinical course BACKGROUND: Management of atrial fibrillation (AF) with rapid ventricular rate in the setting of submassive pulmonary emboli (PE) has not been well defined in the literature. It is challenging as the hemodynamics caused by a PE can change the management of AF. We report a case of bilateral PE masked by new-onset AF with rapid ventricular rate that was treated pharmaceutically and mechanically, with thrombectomy. CASE REPORT: An 85-year-old man presented with gradual dyspnea and was found to be in AF with rapid ventricular rate (~160–180 bpm). The patient had tachypnea and hypoxia requiring oxygen administration. On physical examination, he had euvolemia. Chest X-ray did not reveal pulmonary vascular congestion. He was started on standard AF management with atrioventricular nodal blockers. Laboratory tests revealed a normal troponin level but mildly elevated B-type natriuretic peptide and lactate. Because his dyspnea was out of proportion to the physical examination, radiographic, and laboratory findings, a D-dimer level was obtained and was elevated. Computed tomography with pulmonary angiogram showed extensive bilateral PE. An echocardiogram (TTE) showed evidence of right ventricular failure. The patient underwent mechanical thrombectomy with clot retrieval, deterring the risk of hemodynamic collapse that would have ensued with atrioventricular nodal blockers monotherapy. On repeat TTE, right ventricular dysfunction was completely resolved and the remaining hospitalization was uneventful. CONCLUSIONS: In patients with concomitant AF with rapid ventricular rate and submassive PE, the use of mechanical thrombectomy, in addition to the standard AF management, could be beneficial in deterring the risk of hemodynamic collapse.