1. RVT & PE

2. 35 years old F , 95 kg
ED 11122013 6:30 pm
CC: Dyspn, asthenia
Cs 19 days , wound infection
Neg past Hx: G7P7
AVPU: 4
HR: 140 reg
RR:40
SBP: 110
SPO2 : 84
TEMP : 37.2
UOP:30 mlhr
JVP : raised
Chest clear , heart NDA , no leg swelling or pain

3. ECG: ST
ECHO : RVT (4cm) , RV Dil( 2 LV) , RV Dysf , RV
global hypok
D-Dimer: 4000
PCV:
Platel , BU , Scr , RBS , SGOT , SGPT , Fibrenogin ,
WBCC , PT , PTT ,ESR , Ca, CXR: nl
LA , AC , ANA : -VE
Dx: RVT + PE
(hypercoag due to stasis , RFs: immobil , surgery , infect , preg )

4. CTPA
MRA
CT Chest with contrast
Doppler
Diagnostic imaging tests compare (inDx of intracardiac thrombi)
1- TTE : 23%
2-TEE: 40%
3- Contrast enhanced echo : 60%
4- Delayed enhanced MRI : 90%

5. Rx:
- UF Hep 80ukg then 18ukghr
- Merop 1g x3 ( in 200ml NS)
- O2
D6: Change UFH to Enox 1mgk x2 + warf 5mg

6. UOP
mlhr
RV
size
RVT
size
cm
DYSP SBP SPO2
wo
O2
RR HR DAY
30 4
float
+++ 110 82 40 140 1
50 2x
LV
2.4 ++ 115 84 34 115 4
100 dec 1.2
Organ
+ 130 89 32 105 6

7. Discussion

8. 1- surgical removal : not available
2- thrombolysis : risk of bleeding , and
dislodgment
3- catheter thrombus removal : not available
4- anticoagulant

9. Optimal therapy of intracardiac thrombi has
not been defined .
1- surgical embolectomy
2- thrombolysis
3- catheter thrombus removal
4- anticoagulant
Mortality is high (44%) irrespective of therapeutic
option chosen ( Ludovic C : circul 1998)

10. Circul :
Emergency surgery is usually advocated .
Thrombolysis is a faster promising treatment
In patients with ct to surgery or lytic ,
interventional technique

11. Surgical removal
For large mobile thrombi with high risk of embolization

12. UF Heparin inf is most effective in LVT
Thrombus size dec in (100%) pt and
Disappear in (83 % ) within 7-22 days

13. Enoxaparin used >> UFH in PE
But
RVT +PE : UFH inf >>> enoxap
Why:
Rapid reversibility :
Consideration of urgent need for thrombolysis

14. UFH inf
After bolus dose : Start 18 ukghr
PTT target 60-80
PTT every 6 hrs → inc dose : then daily PTT
( low PTT doesn’t mean antithromb failure , and high PTT doesn’t mean
inc bleeding rate)
platel count Daily : risk of HIT in high dose