APCU25CR24 Beating the clock: the critical role of timely action in massive pulmonary embolism

Introduction Acute pulmonary embolism (PE), a potentially fatal condition, can cause hemodynamic instability, right ventricular failure, and sudden death.Case Presentation A 51-year-old Malay woman with diabetes mellitus and bronchial asthma presented with syncope, vomiting, and worsening dyspnea for 3 days. In addition to being para 7 + 4 (including twins), with recurrent miscarriages in her last two pregnancies, she had no prior thrombotic events. Besides taking Maajun pills for 4–5 months, she denied autoimmune or malignancy symptoms. Her family history was unremarkable. Her menses were regular, without usage of contraception. On admission, she was tachypneic, hypotensive (blood pressure, 109/54 mmHg), tachycardic (heart rate, 123 bpm), and hypoxic (SpO&noentity8322; of 90% on room air). Lung auscultation was clear; however, cardiovascular examination revealed a gallop rhythm without overt heart failure. Her calves were soft and non-tender. Electrocardiogram demonstrated sinus tachycardia, with an S1Q3T3 pattern and Q waves in V1–V4. D-dimer levels were high (4961 ng/mL), with normal troponin I and other blood parameters. Chest X-ray imaging showed Palla’s sign, whereas echocardiography revealed preserved function and right ventricular dilatation, with a D-shaped left ventricle.Results Computed pulmonary angiography confirmed a massive saddle PE, pulmonary hypertension, and infarction of the left upper lobe. She was started on low-molecular-weight heparin, followed by intravenous heparin. Subsequently, the patient required noninvasive ventilation and was transferred for emergency pulmonary embolectomy under cardiopulmonary bypass. Multiple emboli were extracted from the distal left main pulmonary artery and its branches. Postoperatively, she experienced cardiac tamponade that necessitated surgical re-exploration, which revealed clots compressing the right atrium and hemorrhagic pleural collection. Her condition was complicated by hospital-acquired infection, wound dehiscence, and lacunar stroke. A month later, she was discharged in stable condition, with rivaroxaban. Follow-up echocardiography revealed preserved ejection fraction (64%) with trivial TR. Autoimmune panel and tumor markers were negative.Discussion Surgical embolectomy was lifesaving in this case of massive PE, which dramatically improved the prognosis. Repeat antiphospholipid antibody screening and further imaging are warranted to explore the cause of this unprovoked event.Conclusion This case highlights the value of early surgical intervention in complex or high-risk PE.