Dr. Hemant P. Pathare
Sr. Consultant
CTS Heart & Lung Transplant
Nanavati Super Speciality
Hospital, Mumbai

THE CASE

A 56 year old man suffering from Orthopnoea for past 3-4 days was admitted to Nanavati Super Speciality Hospital, Mumbai. He had been operated for Osteogenic Sarcoma of the right thigh 3 year ago, and was treated with redo replacement of the previous prosthesis 3 months ago at another hospital. The patient had a history of Pulmonary Embolism and was on treatment with oral anticoagulants thereafter till it was stopped for repeat Orthopaedic surgery.

The patient was chronic hypertensive; his clinical examination revealed a large mobile mass, thrombus in the right atrium prolapsing into the right ventricle, moderate tricuspid regurgitation, severe pulmonary arterial hypertension, a dilated right atrium and right ventricle. CT Chest showed a large thrombus in right atrium, pulmonary embolism to right and left pulmonary artery including upper and lobar branches and multiple nodules in lungs suggestive of metastasis. ECG revealed sinus tachycardia with right ventricular strain.

THE PROCEDURE

Patient was taken up for emergency surgery and underwent removal of large thrombus from RA, bilateral pulmonary arterial thrombectomy. o Thromboendarterectomy of Right PA under deep hypothermia (21 C) and low flow cardio pulmonary bypass under trans esophageal guidance, with insertion of Intra Aortic Ballon (IAB) was done. A large tubular 30 cm x 2 cm thrombus was extricated from the right atrium, there was mild tricuspid regurgitation caused by a tear seen in the anterior tricuspid leaflet, chronic plus acute thrombi clogging the entire proximal LPA & RPA all the way upto lobar branches. The left ventricle was hypertrophied.

THE RESULT

The patient was shifted to the ICCU after a 12 hour surgery on temporary atrio-ventricular sequential pacing, adrenaline, milrinone and IAB support (1:1). Long acting Heparin i.e. Fondaparinux was started on post operative day 1 along with Warfarin. Injection Fondaparinux was continued till the day of discharge. An inferior vena caval filter was electively placed on post operative day 6 via right femoral venous route.

The patient recovered well and was discharged by post operative day 10. The patient followed up after 3 months with near normal pulmonary artery pressures on 2D echo and is now back to a normal life.