APCU25CR12 The trail of bullet: persistent pulmonary hypertension as a sequelae of massive pulmonary embolism

Introduction Persistent pulmonary hypertension is an uncommon outcome from the obstruction of pulmonary arteries caused by pulmonary embolism resulting in increased pulmonary vascular resistance. We report a case of persistent pulmonary hypertension from resolved massive pulmonary embolism.Case Presentation A 40-year-old nulliparous lady was first presented with a 2-week history of failure symptoms. Prior to this, she was under gynecology follow-up for her uterine fibroid, which requires regular tranexamic acid for her menorrhagia. Otherwise, there was no history of long-haul travelling, malignancy, hormonal therapy usage, or family history of clotting disorder. Upon presentation, she was alert but tachypneic under room air with persistent tachycardia of 100-125. Her blood pressure was normal. Acute pulmonary embolism was suspected as she remains hypoxic. An urgent CT Pulmonary Angiogram (CTPA) was ordered, revealing filling defect at both right and left main pulmonary arteries extending to the segmental branches, suggestive of massive bilateral pulmonary embolism. Echocardiogram (ECHO) showed severe pulmonary hypertension with PASP of 70 mmHg, without right ventricle dysfunction or septal defect. Her Troponin I was normal. She was hemodynamically stable, with low Pulmonary Embolism Severity Index (PESI) score of class 2; hence, she was not subjected to thrombolysis. She was treated with oral anti-coagulant for 6 months. Screening for anti-phospholipid syndrome was negative. ANA and ANCA were both negative. Repeated CTPA after completion of oral anticoagulant showed complete resolution of pulmonary embolism. However, repeated ECHO during follow up after 1 year revealed persistent pulmonary hypertension of PASP 44 mmHg. She was otherwise asymptomatic. She underwent laparotomy myomectomy for her multiple uterine fibroids. HPE reported as leiomyomata with no evidence of malignancy.Discussion Investigating the primary cause of thromboembolism is important to prevent recurrent thrombosis and determine the duration of treatment. As other workup was negative, this suggests that tranexamic acid usage has a possible increased risk of thrombotic event.Conclusion This case highlights that persistent right heart strain due to the vascular remodeling from previous thromboembolism may persist even after complete resolution of thrombus. Follow- up ECHO is essential to monitor patient progress, should further intervention is needed.