IOTW 3/02/21

64 y/o M p/w dyspnea

  1. What are labels A and B referring to?
    • These are clots in transit. They are occasionally seen in the setting of pulmonary embolism (4-18% of cases). In this case they were visualized traversing the tricuspid valve from right atrium to right ventricle.
  2. How does this finding affect prognosis?
    • This is a poor prognostic factor. The mortality of patients with PE without RV thrombus ranges between 11-16% whereas the presence of clot in transit raises mortality to at least 44%.
  3. Name 2 other signs of RV strain seen in the images above.
    • Dilated RV. Note the RV:LV ratio even in this parasternal short axis view is >1:1.
    • Interventricular septal dependence. In the parasternal short axis view, this is also called the “D sign” where the left ventricle forms the shape of the letter “D” due to elevated right ventricle pressures combined with lower left ventricle pressures due to the obstructive physiology proximal to the pulmonary arteries.
  4. What are some treatment options available other than anticoagulation or systemic thrombolysis?
    • Although more research is needed in regards to treatments such as endovascular therapy, options include: catheter-directed thrombolysis, surgical embolectomy, mechanical thrombectomy, suction thrombectomy, and IVC filter.
  5. How would you dose alteplase in the setting of massive pulmonary embolism? What about in the setting of cardiac arrest?
    • Numerous dosing regimens have been implemented. The most common method is Alteplase 100 mg (full dose) or 50 mg (half dose) IV administered over 2 hours. In cardiac arrest, you can give Alteplase 50 mg IV administered over 60 seconds. It is recommended to continue CPR for at least another 15 minutes if not longer (some guidelines suggest 30-60 minutes) to allow thrombolysis time to work. Be sure to familiarize yourself with the thrombolytic contraindications.

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