The unfortunate miss: a saddle pulmonary embolism

Abstract

Pulmonary embolism is a potentially life-threatening condition that requires prompt diagnosis and efficient management such as in the form of thrombolysis or surgical thrombectomy. Saddle pulmonary emboli occurring at the bifurcation of the pulmonary artery are especially dangerous as they put afflicted individuals at risk for sudden hemodynamic collapse. While CT Angiography at present is the current imaging modality of choice, times exist when they are contraindicated and V/Q scintigraphy is used as the choice alternative. We present a rare catastrophic case of a saddle pulmonary embolism in an individual with a low-probabilityinterpretation on V/Q scintigraphy despite a clear depiction of the thrombus on echocardiography.Keywords: Pulmonary; Embolus; Thrombus; Thrombolysis; Echocardiogram. ReleasesThis article has never been published previously, and it is not under consideration from publication elsewhere. The publication is approved by all authors and tacitly by the responsible authorities where the work was carried out, and if accepted, it will not be published elsewhere including electronically in the same form, in English or in any other language, without the written consent of the copyright-holder. CaseOur patient was a 70-year-oldfemale with a history of COPD, paroxysmal atrial fibrillation, congestive heart failure (HFrEF), type 2 diabetes mellitus, and non-small cell lung carcinoma (NSLCL) who presented with symptoms of bilateral lower extremity swelling, dyspnea on exertion and generalized weakness. Admitted for acutely decompensated heart failure, there was some suspicion for pulmonary embolism (PE) as the patient experienced oxygen saturation of 90% despite supplemental oxygen.Her other vital signs were otherwise unremarkable save for a heart rate of 121 beats/minute. Pertinent physical examination findings included elevated jugular venous pressure at 5 cm above the sternal angle, bibasilar pulmonary fine crackles, and bilateral lower extremity 1+ pitting edema. Because of an allergy to contrast dye and low Well's score, a V/Q scan was opted for in lieu of thoracic computed tomography angiography (CTA) with results suggesting low probability of a PE as there were matching perfusion and ventilation defects (Figure 1). A subsequent echocardiogram performed showed extensive right ventricular (RV) dilatation with interventricularseptal bowing and an echogenic focus in the pulmonary artery (PA) concerning for a saddle PE (Figures 2 and 3). However, despite intravenous heparin infusion, the patient decompensated with acute hypoxemic respiratory failure and died after comfort care measures were agreed upon.