International Journal of Collaborative Research on Internal Medicine & Public Health

Keywords

Pulmonary embolism, Coronary bypass graft

Case

A 56-year-old-gentleman had triple coronary artery by-pass graft done for severe coronary artery disease. Patient was seen in clinic after one month of surgery with complaint of shortness of breath for 3 days. His blood pressure was 115/55 mm of Hg, Heart rate 50, respiratory rate 25 and oxygen saturation 90% on room air. Considering risk of pulmonary embolism after surgery, patient was sent to radiology for CT pulmonary angiogram which showed large “saddle pulmonary embolism” explaining patient`s symptoms. Patient was immediately started on unfractionated heparin and later started on rivaroxaban therapy after clinical improvement.

Saddle pulmonary embolism means a large embolism of main pulmonary artery often extending into both right and left pulmonary arteries. If large enough, it can cause right heart failure. About 3 to 6 per cent of patients with pulmonary embolism present with a saddle embolus and only 22 per cent are hemodynamically unstable with a mortality rate of 5 percent [1]. Most patients with saddle pulmonary embolism are hemodynamically stable on presentation and do not require thrombolytic therapy or other interventions and respond to usual treatment with anticoagulation. In 5 randomized controlled trials it was seen that patients with massive PE, fibrinolysis reduced the risk of death or recurrent PE by 55% [2].

Figure 1: Saddle pulmonary embolism.

References

1. Ryu JH., Pellikka PA., Froehling DA., Peters SG., Aughenbaugh GL. Saddle pulmonary embolism diagnosed by CT angiography: frequency, clinical features and outcome. Respir Med 2007; 101: 1537.
2. Wan S., Quinlan DJ., Agnelli G., Eikelboom JW. Thrombolysis compared with heparin for the initial treatment of pulmonary embolism: a meta-analysis of the randomized controlled trials. Circulation 2004; 110: 744–749.