Eduardo S. Pérez, BS
Jorge F. García, BS
Christopher A. Rodríguez, BS
Edwin Rodríguez, MD

Universidad Central del Caribe, School of Medicine, Bayamón, Puerto Rico
San Juan Bautista School of Medicine, Caguas, Puerto Rico
Cardiovascular Center of Puerto Rico and the Caribbean, San Juan, Puerto Rico

Introduction

A 55-year-old male, with a history of type 2 diabetes mellitus, hypertension, and two previous episodes of deep venous thromboses (DVT) (2017 and 2021), presented with a 2-day history of nausea, vomiting, weakness, and syncope. Medical history was significant for discontinued anticoagulation therapy (rivaroxaban) due to insurance issues, and current medications included lisinopril, atorvastatin, and metformin. In the emergency department, initial examination revealed an anxious but alert patient with normal heart sounds and no respiratory distress. He experienced cardiac arrest, manifesting as atrial fibrillation progressing to ventricular fibrillation, requiring 7 to 8 minutes of ACLS protocol. Post-resuscitation electrocardiograms revealed anterior STEMI, complete AV block, and atrial flutter. An emergent cardiac catheterization demonstrated 90% proximal LAD and 30% distal RCA stenosis. A temporary ventricular pacemaker was placed under fluoroscopic guidance. Later, bedside 2D echocardiogram identified a pedunculated and very mobile echodense structure, compatible with a large thrombus in the inferior vena cava-right atrial junction. Three days later, after initial presentation, mechanical thrombectomy was performed successfully. Pulmonary arteriograms were performed and showed poor perfusion in the right upper lobe, raising concern for an acute pulmonary embolism. However, further intraprocedural imaging revealed that poor flow resulted from severe pulmonary artery stenosis of the secondary branches supplying the upper right lung, most likely due to chronic embolisms rather than an acute event.

Methods

The patient underwent successful angioplasty of the right upper lobe pulmonary artery branches with improved perfusion after the intervention.

Results

The hospital course concluded with stabilization on anticoagulation, dual antiplatelet therapy, implantation of an intravenous cardiac defibrillator with resynchronization therapy, and glycemic control.

Conclusion

This case demonstrates the use of new therapies for rare but life-threatening complications of arrhythmias and myocardial infarctions, such as cardiac thrombosis, and how comprehensive vascular assessment during cardiac interventions can reveal clinically silent but significant pulmonary vascular remodeling in asymptomatic post-thrombotic patients.