Fasullo Sergio, Scalzo Sebastiano, Maringhini Giorgio, Ganci Filippo, Giubilato Alfonso, Cannizzaro Sergio, Baglini Roberto, Cangemi Debora, Terrazzino Gabriella, Paterna Salvatore, Di Pasquale Pietro
Int J Emerg Med. 2010 Jul 21;3(3):197-9. doi: 10.1007/s12245-010-0193-9.
A 68-year-old man was referred to the emergency department 6 h after onset of sudden acute dyspnoea. Immediate ECG showed sinus tachycardia with the typical S1-Q3-T3 pattern and incomplete right bundle branch block. The echocardiogram showed the presence of mobile thrombus in the right atrium, a distended right ventricle with free wall hypokinesia and displacement of the interventricular septum towards the left ventricle. Lung spiral computed tomography (CT) showed bilateral pulmonary involvement and confirmed the picture of a thrombotic system in the right atrium and caval vein. Thrombolytic treatment with recombinant tissue plasminogen activator (rt-PA) and heparin (alteplase 10 mg bolus, then 90 mg over 2 h) was administered. Six hours after thrombolysis bleeding gums and significant reduction in platelet count (around 50,000) were observed. Heparin was discontinued and bivalirudin (0.1 mg/kg bolus and 1.75 mg/kg per h infusion) plus warfarin was initiated and continued for 5 days until the international normalised ratio (INR) was within the therapeutic range (2.0-3.0) for 2 consecutive days, with concomitant platelet count normalisation. Lung spiral and lower abdominal CT before discharge did not show the presence of clots in the pulmonary arteries of the right and left lung. This case suggests that bivalirudin could offer promise for use in patients with heparin-induced thrombocytopaenia (HIT) after thrombolysis for massive pulmonary embolism.
一名68岁男性在突发急性呼吸困难6小时后被送往急诊科。即刻心电图显示窦性心动过速，伴有典型的S1-Q3-T3图形和不完全性右束支传导阻滞。超声心动图显示右心房有活动血栓，右心室扩张，游离壁运动减弱，室间隔向左心室移位。肺部螺旋计算机断层扫描（CT）显示双侧肺部受累，并证实了右心房和腔静脉内血栓形成的情况。给予重组组织型纤溶酶原激活剂（rt-PA）和肝素（阿替普酶10mg静脉推注，然后在2小时内输注90mg）进行溶栓治疗。溶栓6小时后，观察到牙龈出血和血小板计数显著降低（约50,000）。停用肝素，开始使用比伐卢定（0.1mg/kg静脉推注，然后以1.75mg/kg每小时输注）加华法林，并持续5天，直到国际标准化比值（INR）连续2天处于治疗范围（2.0-3.0），同时血小板计数恢复正常。出院前的肺部螺旋CT和下腹部CT显示左右肺肺动脉内均无血栓。该病例提示，比伐卢定在大规模肺栓塞溶栓后肝素诱导的血小板减少症（HIT）患者中可能具有应用前景。
