LIFE SAVING PULMONARY
A Matter of the Heart and Science
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.
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
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.