Thrombosis of the right atrium in acute massive pulmonary embolism: a clinical case of effective thrombolysis by alteplase in a patient with unstable hemodynamics

The article presents a clinical case of treatment of a patient with acute massive pulmonary embolism. A 70-year-old patient was urgently admitted to the intensive care unit with complaints of sudden onset of chest pain for the first time, severe shortness of breath and two episodes of syncope in the last 4 hours. When the patient was admitted to the hospital, the heart rate was 131 beats / min, blood pressure was 80/50 mm Hg, SpO2 was 88 %, and PO2 was 76 mm Hg. Echocardiographically revealed dilated right atrium and right ventricle, hyperechogenic «floating» formation of the right atrium; moderate tricuspid regurgitation and pronounced pulmonary hypertension with systolic pressure in the pulmonary artery ~ 63 mm Hg were observed, and preserved systolic function of the left ventricle; inferior vena cava 20 mm, on the udder did not fall. It was urgently decided to carry out thrombolytic therapy to the patient in connection with unstable hemodynamics. The patient was started administration of alteplase according to the accelerated scheme: 10 mg of tissue plasminogen activator as an intravenous bolus for 1 minute of administration, then – intravenous infusion of alteplase 90  mg for the next 2 hours until the maximum total dose of 100 mg. Three hours after thrombolytic therapy – hemodynamic parameters of the patient had a positive dynamics: blood pressure – 125/80 mm Hg, pulse – 76/min, SaO2 – 98 %, PO2 – 90 mm Hg. On transthoracic echocardiography – no thrombus in the right atrium and right ventricle, as well as a small tricuspid regurgitation, with slight pulmonary hypertension (PsystRV – 36 mm Hg). This clinical case demonstrates thrombolysis with alteplase – «rescue therapy» and a fairly effective treatment option for patients with unstable hemodynamics, acute massive pulmonary embolism, complicated by thrombosis of the right atrium and/or right ventricle and existing hypertensive.