Presentation
Several days of SOB.
Patient Data
Saddle pulmonary embolus that extends into the left and right pulmonary arteries, and into the segmental and subsegmental arteries throughout all lobes. Interlobar septal thickening throughout the bilateral lung fields, likely reflective of pulmonary edema. Atelectasis within the bases. No confluent consolidation. No pleural effusion. No pneumothorax..
Pulmonary trunk dilatation to 31 mm. Cardiomegaly with marked right atrial and right ventricular dilatation, and flattening of the interventricular septum. There is reduced volume within the left atrium and ventricle. Within the right atrium, there is hypodense filling defect which appears to extend through the intra-atrial septum and to the left ventricle. Trace pericardial effusion, likely within physiologic limits. Reflux of contrast into the suprahepatic IVC.
Impression
1. Saddle pulmonary embolus which extends throughout the pulmonary arterial tree to the subsegmental level within all lobes. CT features of severe right heart strain with associated widespread pulmonary edema.
2. Thrombus within the right atrium appears to communicate across the intra-atrial septum into the left atrium. This raises concern for a patent foramen ovale and could be better assessed with echocardiogram.
Case Discussion
The patient had neurological symptoms, and a CT showed multifocal embolic infarcts. IV thrombolysis was contraindicated. The IR team successfully performed mechanical thrombectomy of the PE and inserted an IV filter.
Echo with agitated saline contrast (bubble study) did not demonstrate a PFO or ASD at rest or with Valsalva.
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