Schreinlechner Michael, Geiger Ralf, Mair Johannes
Department of Internal Medicine III - Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria.
Department of Child and Adolescent Health, Pediatrics III - Cardiology and Pulmology, Medical University Innsbruck, Innsbruck, Austria.
J Cardiol Cases. 2021 Dec 31;25(6):326-329. doi: 10.1016/j.jccase.2021.12.004. eCollection 2022 Jun.
A 22-year-old woman with complete Fontan palliation for tricuspid valve hypoplasia and chronic anemia presented to a local hospital for swelling of her left arm. Initially, the patient was hemodynamically stable without dyspnea or chest pain. Admission hemoglobin was 53 g/L and D-dimer 0.51 mg/L. Sonography showed signs of venous congestion of the left arm, but no definitive signs of venous thrombosis. Subsequently she developed dyspnea with a decrease in transcutaneous oxygen saturation to 85%. Computed tomography angiography revealed bilateral pulmonary embolism with occlusion of the right pulmonary artery. The patient was transferred to a tertiary care center. Gastroscopy detected only small stomach ulcers, and because of ongoing hemodynamic instability, the decision was to initiate rescue ultrasound-assisted catheter-directed local thrombolysis. This treatment was effective with rapid hemodynamic stabilization without bleeding complications and without residual emboli in a long-term follow-up cardiac catheterization. < Awareness of acute pulmonary embolism as a life-threatening condition in Fontan palliation and of ultrasound-assisted catheter-directed local thrombolysis as an effective rescue treatment option for hemodynamically unstable patients with acute pulmonary embolism and bleeding risk. Thrombosis of the subclavian vein may be missed in ultrasound examination and may also present with an admission D-dimer concentration within normal limits.>.
一名22岁女性，因三尖瓣发育不全接受完全性Fontan姑息手术，患有慢性贫血，因左臂肿胀入住当地医院。最初，患者血流动力学稳定，无呼吸困难或胸痛。入院时血红蛋白为53 g/L，D-二聚体为0.51 mg/L。超声检查显示左臂有静脉充血迹象，但无明确的静脉血栓形成迹象。随后，她出现呼吸困难，经皮血氧饱和度降至85%。计算机断层血管造影显示双侧肺栓塞，右肺动脉闭塞。患者被转至三级医疗中心。胃镜检查仅发现小胃溃疡，由于血流动力学持续不稳定，决定启动抢救性超声引导下导管直接局部溶栓治疗。该治疗有效，血流动力学迅速稳定，无出血并发症，长期随访心脏导管检查无残余栓子。<认识到急性肺栓塞在Fontan姑息治疗中是一种危及生命的疾病，以及超声引导下导管直接局部溶栓作为急性肺栓塞且有出血风险的血流动力学不稳定患者的一种有效抢救治疗选择。超声检查可能漏诊锁骨下静脉血栓形成，且入院时D-二聚体浓度可能在正常范围内。>
