DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20173599

Case of acute pulmonary embolism in post pneumonectomy-a rare clinical presentation and management

Manjunath B. V., Bhabani Sahoo, Gaurav Thakre, Nitin Gudage

Abstract


With a history of right pneumonectomy, pulmonary embolism affecting bilateral pulmonary artery is rare and needs to be meticulously managed to prevent pulmonary infarction of the normal lung with a clinical decision regarding thrombolysis. A 64 years male diabetic and hypertensive with a history of right pneumonectomy 10 years back, presented to ER with dyspnea and 2 episodes of syncope with right leg pain and swelling for 3 days. BP was 140/90mmHg and pulse rate of 100/min. SPO2 in room air was 95%. ECG suggested S1Q3T3 with sinus tachycardia. Echocardiogram revealed features of pulmonary embolism. Venous doppler of right leg showed DVT and CT Pulmonary angiogram was suggestive of pulmonary embolism. High-sensitive troponin I and NT-pro BNP were negative. Diagnosis of submassive pulmonary embolism was made. Protecting the normal lung from infarction was of paramount importance. There was no indication for thrombolysis. Treatment with LMWH was initiated and overlapped with the novel oral anticoagulant (NOAC) dabigatran. Symptomatically patient improved along with a reduction in pulmonary arterial hypertension and improved RV function. Post pneumonectomy of one lung, protecting the normal lung from infarction is utmost important in a setting of pulmonary embolism. It is a rare case scenario. Clinical decision regarding thrombolysis should be taken carefully. In this case thrombolysis was not indicated as per guidelines. LMWH, oral anticoagulation and broad-spectrum antibiotic to prevent secondary lung infection are the mainstay in the treatment of submassive pulmonary embolism where thrombolysis is not indicated.


Keywords


Clinical decision, Oral anticoagulation, Pneumonectomy, Pulmonary Embolism, Pulmonary infarction, Thrombolysis

Full Text:

PDF

References


Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American heart association. Circulation. 2011;123(16):1788-830.

Piazza G, Goldhaber SZ. Management of submassive pulmonary embolism. Circular. 2010;122:1124.

Meyer G, Vicaut E, Danays T, Agnelli G, Becattini C, Beyer-Westendorf J, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370(15):1402-11.

Bauer KA. Recent progress in anticoagulant therapy: oral direct inhibitors of thrombin and factor Xa. J Thromb Haemost. 2011;9(1):12.

Schulman S, Kearon C, Kakkar AK, Mismetti P, Schellong S, Eriksson H, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med. 2009;361(24):2342-52.

Schulman S, Kearon C, Kakkar AK, Schellong S, Eriksson H, Baanstra D, et al. Extended use of dabigatran, warfarin or placebo in venous thromboembolism. N Engl J Med. 2013;368(8):709-18.

Goldhaber SZ, Piazza G. Optimal duration of anticoagulation after venous thromboembolism. Circulation. 2011;123:664.

Nagasaki F, Flehinger BJ, Martini N. Complications of surgery in the treatment of carcinoma of the lung. Chest. 1982;82:25-9.

Klatsky AL, Armstrong MA, Poggi J. Risk of pulmonary embolism and/or deep venous thrombosis in Asian-Americans. Am J Cardiol. 2000;85:1334-7.

Ziomek S, Read RC, Tobler HG, Harrel JE, Gocio JC, Fink LM, et al. Thromboembolism in patients undergoing thoracotomy. Ann Thorac Surg. 1993;56:223-6.

Schmid C, Zietlow S, Wagner TO, Laas J, Borst HG. Fulminant pulmonary embolism: symptoms, diagnostics, operative technique and results. Ann Thorac Surg. 1991;52:1102-5.

Kalweit G, Huwer H, Volkmer I, Petzold T, Gams E. Pulmonary embolism-a frequent cause of fatality after lung resection. Eur J Cardiothorac Surg. 1996;10:242-7.

Kamayema K, Huang CL, Liu D, Okamoto T, Hayashi E, Yamamoto Y, et al. Pulmonary embolism after lung resection: diagnosis and treatment. Ann Thorac Surg. 2003;76:599-601.

Chen Q, Tang AT, Tsang GM. Acute pulmonary thromboembolism complicating pneumonectomy: successful operative management. Eur J Cardiothorac Surg. 2001;19:223-5.

Kopec SE, Irwin RS, Umali-Torres CB, Balikian JP, Conlan AA. The postpneumonectomy state. Chest 1998;114:1158-84.