Sub-Massive Pulmonary Embolism with Large Intra-Cardiac Bi-Atrial Thrombi Successfully Treated with Systemic Thrombolytic Therapy Tawfik Khoury *# , Sara Hoss # , Ronen Durst, Joseph Kalish and Arthur Pollak Department of Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel # Contributed equally * Corresponding authors: Tawfik Khoury, Department of Medicine, Hebrew University-Hadassah Medical Center, P.O.B. 12000, Jerusalem, Israel, Tel: 972-2-6777816; Fax: 972-2-6431021; E-mail: Tawfkkhoury1@hotmail.com Received date: November 26, 2016; Accepted date: December 08, 2016; Published date: December 10, 2016 Copyright: © 2016 Khoury T, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract Herein we report a case of 46-year-old male patient who was presented with chest pain and dyspnea and was diagnosed with sub-massive pulmonary embolism (PE) and intra-cardiac bi-atrial thrombus, echocardiography showed decreased right ventricular systolic function. Following treatment with 100 mg tissue plasminogen activator (tPA), the patient reported clinical improvement, in addition to improved ventricular function as assessed by echocardiography. In the present report, we describe a case of sub-massive PE with intra-cardiac bi-atrial thrombus successfully managed with thrombolytic treatment without occurrence of adverse events. Keywords: PE; Intra-cardiac thrombi; Trombolysis; Adverse efects Introduction Patients with pulmonary embolism are evaluated and classifed into three separate groups to determine the appropriate treatment. Patients with acute massive PE, presenting with hemodynamic instability, have an indication for thrombolytic treatment. Patients with sub-massive PE, although hemodynamically stable, may be considered for thrombolytic treatment if signs of right ventricular (RV) dysfunction are present. Hemodynamically stable patients without signs of RV dysfunction have no indication for thrombolytic therapy and are treated with anticoagulation only [1]. Right atrial thrombi are encountered in approximately 18% of cases with acute massive PE, and are associated with higher mortality, most likely due to high risk of fragmentation and recurrent pulmonary emboli [2,3]. However, thrombolytic treatment was associated with an improved survival when compared to anticoagulation therapy or surgery in right heart thromboembolic disease [4]. Tis is further supported by several case reports, in which thrombolytic treatment was noted to dissolve right atrial thrombi without adverse efects [5,6]. Treatment for lef atrial thrombi is debatable. A thrombus in the lef atrium is associated with potentially catastrophic consequences due to the risk of fragmentation and subsequent systemic embolization which could cause stroke, myocardial infarction and visceral or limb ischemia. Partial or total occlusion of the mitral valve orifce that may cause syncope or pulmonary congestion was also reported [7]. Currently, there are no consensus guidelines for the treatment of lef atrial thrombus, however based on professional societies recommendation for prosthetic valve thrombosis (PVT) treatment, thrombolytic therapy can be considered as a frst line treatment for lef atrial thrombi. Herein, we report a case of sub-massive PE concomitantly diagnosed with intra-cardiac bi-atrial thrombi who was successfully treated with thrombolytic therapy. Case Report 46 years old male presented to the emergency department with chest pain and dyspnea that begun one day prior to his admission. Te patient's medical history was notable for obesity, Kleinefelter's syndrome and two previous thromboembolic events. On arrival, the patient's blood pressure was 134/96 mmHg, tachycardia of 110 bpm, body temperature 36.7 Celsius, tachypnea of 26 breaths per minute and room air O 2 saturation was 94%. On examination, he had mildly elevated jugular venous pressure, normal heart sounds without murmurs or pericardial friction rub. Lungs were clear to auscultation. Upper and lower limb pulses were equal bilaterally. Te rest of the physical examination was unremarkable. Electrocardiography showed sinus tachycardia, inverted T wave in the precordial leads and S1Q3T3 pattern. Chest X-ray was normal. Blood tests revealed white cell count of 16,700 per cubic millimeter (range 4,000-10,000 per cubic millimeter). Blood gas analysis showed respiratory alkalosis, D-Dimer level was more than 15 mcg per milliliter (normal range 0-0.5 mcg per milliliter). C reactive protein (CRP) level was 2.2 mg% (normal values <0.5). Serum electrolytes, creatinine, creatine phosphokinase (CPK) and high sensitivity -troponin T levels were normal. Pulmonary CTA revealed bilateral central and peripheral pulmonary embolism (PE) and large thrombotic masses in both atria (Figure 1). Echocardiography showed severely dilated right ventricle, moderately to severely decreased right ventricular systolic function with diastolic and systolic septal fattening with sparing of the apex consistent with McConnell's sign. In addition, there were large mobile thrombi in both lef and right atria extending to the ventricles (Figures 2-4). Te patient was treated with 100 mg of tissue plasminogen activator (tPA), given as an initial dose of 10 mg bolus and 90 mg over two hours, without side efects. Tere were no embolic or bleeding complications. Shortly afer thrombolysis the patient reported signifcant relief in shortness of breath, O 2 saturation on room air improved and heart rate slowed. Echocardiography performed two hours following the end of thrombolysis showed resolution of the thrombi in both atria. Khoury et al., J Clin Exp Cardiolog 2016, 7:12 DOI: 10.4172/2155-9880.1000485 Case Report Open Access J Clin Exp Cardiolog, an open access journal ISSN:2155-9880 Volume 7 • Issue 12 • 1000485 Journal of Clinical & Experimental Cardiology J o u r n a l o f C l i n ic a l & E x p e r i m e n t a l C a r d i o l o g y ISSN: 2155-9880