Wasserstrum Yishay, Lubetzky Aaron, Goitein Orly, Matetzky Shlomo
Leviev Center of Cardiovascular Medicine, Sheba Medical Center in Tel-Ha'Shomer, Ramat-Gan, Israel, 5232000.
Sackler School of Medicine, Tel-Aviv University, 35th Klatshkin st., Tel-Aviv, Israel, 6997801.
Eur Heart J Case Rep. 2021 Aug 18;5(8):ytab304. doi: 10.1093/ehjcr/ytab304. eCollection 2021 Aug.
Venous thromboembolism (VTE) is a common condition that may manifest as intermediate or high-risk pulmonary embolism (PE), requiring either primary or subsequent fibrinolytic therapy. In these cases, catheter-directed thrombolysis (CDT) has been shown to be beneficial.
We present the case of a borderline obese but otherwise healthy 43-year-old male individual, who was admitted with acute intermediate- to high-risk PE requiring treatment with intravenous unfractionated heparin. After initial therapy failure, the patient received CDT, with subsequent clinical worsening, and a mixed result of imaging studies suggesting partial central worsening and partial peripheral improvement of the thrombotic burden and right ventricular (RV) function. After a multidisciplinary PE response team (PERT) consultation, the diagnosis of heparin-induced thrombocytopenia (HIT) with normal platelet levels was made. Therapy was changed to intravenous bivalirudin, with an excellent clinical response and complete recovery of RV function. The patient was discharged with oral rivaroxaban therapy, and on follow-up was otherwise well.
Apparent failure of thrombolytic therapy for VTE warrants a clinical investigation into possible causes of a pro-thrombotic state. In this case, the diagnosis of HIT was surprising, especially due to only a mild decline in platelet levels that were well within normal range. We also acknowledge the significance of our PERT in the key diagnosis made in this case.
静脉血栓栓塞症（VTE）是一种常见疾病，可能表现为中危或高危肺栓塞（PE），需要进行初始或后续的纤维蛋白溶解治疗。在这些情况下，导管定向溶栓（CDT）已被证明是有益的。
我们报告了一名43岁的男性患者，体重略超重但其他方面健康，因急性中危至高危PE入院，需要接受静脉普通肝素治疗。初始治疗失败后，患者接受了CDT治疗，但随后临床症状恶化，影像学研究结果不一，提示血栓负荷和右心室（RV）功能部分中央恶化、部分外周改善。在多学科PE反应团队（PERT）会诊后，诊断为血小板水平正常的肝素诱导的血小板减少症（HIT）。治疗改为静脉注射比伐卢定，临床反应良好，RV功能完全恢复。患者出院时接受口服利伐沙班治疗，随访时情况良好。
VTE溶栓治疗的明显失败需要对血栓前状态的可能原因进行临床调查。在本病例中，HIT的诊断令人惊讶，尤其是因为血小板水平仅轻度下降，仍在正常范围内。我们也认识到我们的PERT在本病例关键诊断中的重要性。
