Conservatively managed saddle pulmonary embolism

Abstract

Massive, submassive, and nonmassive pulmonary embolism relate to the hemodynamic state, while saddle pulmonary embolus is a purely radiologic term. Patients with saddle embolus often present with hemodynamic compromise. However, treatment depends on the clinical presentation, and stable patients with a saddle pulmonary embolus can respond well to conventional anticoagulation.

CASE HISTORY

A 68‐year‐old man presented with progressive dyspnea and swelling of the right leg over a 3‐day period. He was hemodynamically stable, but required low‐dose oxygen therapy (Table ). Echocardiography showed dilatation of the right‐sided cavities, interventricular septal flattening, moderate tricuspid regurgitation, and an elevated right ventricular systolic pressure of 50 mm Hg. CT pulmonary angiography revealed a saddle pulmonary embolism and multiple bilateral emboli (Figure ). Compression ultrasound confirmed a right‐sided deep vein thrombosis. He was treated initially with tinzaparin and subsequently switched to rivaroxaban. A repeat CT performed 6 days later showed significant resolution of the saddle embolism (Figure ). He was discharged after two weeks. His postdischarge course has been uncomplicated. Echocardiography performed 6 months later showed a normalized right ventricular systolic pressure of 35 mm Hg.

Clinical and biochemical variables at admission

Vital signs
Respiratory rate (per minute)	18
Oxygen saturation (without oxygen supplementation) (%)	90
Oxygen saturation (with oxygen supplementation 3 L/min by nasal cannula) (%)	95
Blood pressure (mm Hg)	133/88
Heart rate (beats per minute)	83
Arterial blood gas analysis (with oxygen supplementation 3 L/min by nasal cannula)
pO2 (kPa)	13.7
pH	7.52
pCO2 (kPa)	3.6
HCO3‐ (mmol/L)	24.9
Blood tests
Fibrin D‐dimer (mg/L)	10.0 (reference: <0.5)
High‐sensitivity troponin I (ng/L)	140 (reference: <47)
N‐terminal pro‐B‐type natriuretic peptide (ng/L)	3.920 (reference: <125)

Clinical and biochemical variables at admission.

Acute CT pulmonary angiography showing a saddle pulmonary embolism and multiple emboli in the arteries supplying all lobes on both sides

Repeat CT pulmonary angiography showing significant resolution of the saddle embolism

Fibrinolysis is first‐line therapy in patients with pulmonary embolism presenting with shock or hypotension. Conversely, most stable patients are treated with conventional anticoagulants. The terminology may be confusing as the terms massive, submassive, and nonmassive describe the hemodynamic state, while saddle embolus is a radiologic term. The latter often worries physicians who may feel inclined to pursue aggressive therapy. However, while such patients more often present with hemodynamic compromise, their prognosis does not significantly differ from those presenting in a stable fashion. Accordingly, treatment depends on the clinical presentation. The present case illustrates that hemodynamically stable patients with a saddle pulmonary embolus can respond well to conventional treatment.

CONFLICT OF INTEREST

None declared.

AUTHOR CONTRIBUTION

AK and VR: wrote the initial draft. MP: performed the echocardiogram and provided expertise in image interpretation and appropriate anticoagulation. All authors participated in collecting patient data (pictures and clinical history), reviewing the literature, interpretation of clinical findings, critical revision of the manuscript for important intellectual content, and approval of the final version.