Presentation
Acute right pleuritic pain and hemoptysis whilst on warfarin for left ventricular thrombi secondary to severe dilated cardiomyopathy.
Patient Data
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Filling defect in subsegmental feeding pulmonary artery with distal pleurally-based convex non-enhancing lung opacity demonstrating a thin dense rim and lower central attenuation with no air bronchograms, typical of hemorrhagic infarction. Subtle regional ground glass opacity is compatible with blood in air spaces. The right pleural collection has higher attenuation compatible with hemorrhage.
4 chamber dilatation and contrast medium reflux into the IVC and hepatic veins due to heart failure. Pacemaker for heart block.
Linear scar with pleural retraction and traction bronchiectasis.
Case Discussion
Pulmonary artery occlusions can cause ischemic endothelial injury, increased capillary permeability and alveolar hemorrhage, exacerbated by high pressure bronchial artery inflow, and warfarin in this case. Central coagulation necrosis is surrounded by a denser rim of hemorrhage and hyperemic inflammation.
Warfarin failed to prevent pulmonary embolism. Thrombophilia screen was negative.
Pulmonary infarctions are typically due to occlusion of arteries <3mm in diameter. When larger branches are occluded, bronchial artery pre- and post-capillary collateral flow commonly prevents infarction. However terminal heart failure with severe hypotension and elevated pulmonary venous pressure both limit collateral flow.
Pulmonary emboli have a predilection for areas of higher perfusion, usually the lower lobes, but apical blood flow may be increased in a recumbent patient. The clinical presentation and appearances are typical for pulmonary infarction and the lesion subsequently healed leaving a linear scar.
The following day heart transplantation was performed with a successful outcome.
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