Ultrasound Images That Speak: Assessing the Therapeutic Decision in the Emergency Department Regarding the Risk-Benefit Ratio of Systemic Thrombolysis in Intermediate-High-Risk Pulmonary Embolism - A Case Report

Sep 30, 2026

Uploaded by Sarah

Management of acute pulmonary embolism in the Emergency Department remains challenging, especially for hemodynamically and respiratory stable patients with minimal symptoms, and becomes far more complex when a mobile right atrial thrombus indicates extreme risk. A 65-year-old man with chronic venous insufficiency presented after transient severe dyspnea; POCUS-TTE showed severe right ventricular dysfunction with a large mobile intracardiac thrombus, and CT pulmonary angiography confirmed intermediate-high-risk PE with extensive bilateral clot burden. Immediate full-dose alteplase was administered, completed without hemorrhage, followed by complete thrombus resolution and improved right ventricular function at 2 hours, highlighting early ED POCUS-TTE-guided thrombolysis as effective and safe even without shock.

LanguageEnglish

CategoryHealthcare

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Pages18

Reading Time45 min

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Case Report Ultrasound Images That Speak: Assessing the Therapeutic Decision in the Emergency Department Regarding the Risk–Benefit Ratio of Systemic Thrombolysis in Intermediate‑High‑Risk Pulmonary Embolism—A Case Report Adela Golea 1,2, Raluca Mihaela Tat 1,2, *, Carina Adam 1, Sonia Luka 1,2, Mirela Anca Stoia 1,3, * and Ștefan Cristian Vesa 4,5 Academic Editor: Mihaela Hostiuc Received: 11 November 2025 Revised: 9 December 2025 Accepted: 18 December 2025 Published: 23 December 2025 Copyright: © 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license. 1 Cluj‑Napoca County Emergency Clinical Hospital, 3‑5 Clinicilor Street, 400347 Cluj‑Napoca, Romania; [adela.golea@umfcluj.ro](adela.golea@umfcluj.ro) (A.G.); [carinaadam17@gmail.com](carinaadam17@gmail.com) (C.A.); [sonia.luka@umfcluj.ro](sonia.luka@umfcluj.ro) (S.L.) 2 Department 6 Surgery, Emergency Medicine Discipline,“Iuliu‑Hatieganu” University of Medicine and Pharmacy, 8 Victor Babes Street, 400347 Cluj‑Napoca, Romania 3 Department 4 Internal Medicine, Cardiology Medicine Discipline,“Iuliu‑Hatieganu” University of Medicine and Pharmacy, 8 Victor Babes Street, 400347 Cluj‑Napoca, Romania 4 Cluj‑Napoca Clinical Hospital of Infectious Diseases, 23 Iuliu Moldovan Street, 400000 Cluj‑Napoca, Romania; [stefan.vesa@umfcluj.ro](stefan.vesa@umfcluj.ro) 5 Department 1 Functional Sciences, Discipline of Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine,“Iuliu‑Hatieganu” University of Medicine and Pharmacy, 23 Marinescu Street, 400337 Cluj‑Napoca, Romania * Correspondence: [raluca.tat@umfcluj.ro](raluca.tat@umfcluj.ro) (R.M.T.); [mirelastoia@yahoo.com](mirelastoia@yahoo.com) (M.A.S.) Abstract Background: The management of acute pulmonary embolism (PE) in the Emergency De‑ partment (ED) remains challenging, particularly in hemodynamically and respiratory stable patients with minimal symptoms. Diagnostic and therapeutic difficulties are further com‑ pounded when the condition is complicated by a mobile right atrial (RA) thrombus, represent‑ ing an extreme‑risk phenotype. Case Presentation: We report the case of a 65‑year‑old male with a single known venous thromboembolism risk factor‑chronic venous insufficiency‑ who presented to the ED following a transient episode of severe dyspnea at home. On admission, he was hemodynamically and respiratory stable, without the need for oxygen supplementation. Arterial blood gas analysis revealed a metabolically compensated aci‑ dosis with elevated lactate, while cardiac biomarkers were moderately increased. Emer‑ gency point‑of‑care transthoracic echocardiography (POCUS‑TTE) demonstrated severe right ventricular (RV) dysfunction and a large, mobile intracardiac thrombus prolapsing through the tricuspid valve. Computed Tomography Pulmonary Angiography confirmed pulmonary embolism and revealed a massive and extensive bilateral thrombotic burden (Qanadli score 32 points) . Given the extreme risk for fatal embolization, immediate full‑ dose systemic thrombolysis with Alteplase (100 mg over 2 h) was initiated in the ED. Thrombolysis was completed without hemorrhagic complications. Follow‑up POCUS‑ TTE at 2 h showed complete resolution of the intracardiac thrombus and significant im‑ provement of RV function (RV/RA gradient reduced from 40 mmHg to 28 mmHg) . Con‑ clusions: This case highlights the effectiveness and safety of early systemic thrombolysis guided by ED POCUS‑TTE in PE with a massive thrombotic burden, complicated by a mo‑ bile intracardiac thrombus, even in the absence of shock. Such prompt intervention may reduce mortality risk in intermediate‑to‑high‑risk PE subsets, despite limited guidance in current clinical recommendations. Keywords: pulmonary embolism; massive thrombotic burden; right atrial thrombus; sys‑ temic thrombolysis; Emergency Depa

FAQs

Why is management difficult for intermediate-high-risk pulmonary embolism in the Emergency Department?

It is challenging when patients are hemodynamically and respiratory stable with minimal symptoms, and even more so when complicated by an extreme-risk phenotype such as a mobile right atrial thrombus.

What diagnostic findings supported the decision to treat in this case?

POCUS-TTE showed severe right ventricular dysfunction with a large mobile intracardiac thrombus prolapsing through the tricuspid valve, and CT pulmonary angiography confirmed pulmonary embolism with a massive and extensive bilateral thrombotic burden.

What was the treatment and what were the short-term outcomes?

Immediate full-dose systemic thrombolysis with alteplase (100 mg over 2 hours) was started in the ED and completed without hemorrhagic complications; follow-up POCUS-TTE at 2 hours showed complete resolution of the thrombus and improved right ventricular function.

Sep 30, 2026

Uploaded by Sarah