Discussion

This case highlights some important points that must be realized at the bedside when managing intermediate-high-risk patients with extensive clot burden in PE. In this patient with PE, interventional radiology was promptly consulted to perform catheter-directed intervention. This approach aligns with the current standard of care, and in a recently published landmark HI-PEITHO trial, it was established that in patients with acute, intermediate-high-risk PE, adding ultrasound-facilitated catheter-directed fibrinolysis improved clinical outcomes [5]. However, the HI-PEITHO trial did not specifically address the issue pertaining to patients with clot-in-transit/PFO. This patient did fit the criteria for inclusion as per the HI-PEITHO trial; however, we argue that if this patient had undergone catheter-directed intervention, there was a potentially devastating risk of breaking off this clot as it straddled across the PFO and bilateral AV valves. The interventional radiologist was unaware of the existence of this PFO, clot size, and extension across the atrial septum into the left atrium and ventricle. Performing a prompt bedside echocardiogram before catheter-directed intervention identified this extensive clot and thereby prompted expedited surgical intervention, which may have prevented a future cerebrovascular event. Many physicians perform bedside echocardiograms to assess RV dysfunction to risk stratify patients, but this is not considered critical before catheter-directed interventions if patients are otherwise deemed suitable for this intervention. Clinical practice guidelines currently emphasize a multiparametric evaluation in patients with PE, which means that echocardiography is often paired with cross-sectional imaging and lab biomarkers to finalize an intervention plan [6]. However, a formal echocardiogram is not mandated before catheter-directed intervention, which in our case confirmed the extent and location of the clot, thereby changing the course of management. This highlights the importance of obtaining an echocardiogram before catheter-directed interventions in patients with massive and submassive PE. We also believe that surgical embolectomy may be the only definite and viable option when the risk of stroke and systemic embolization is perceived in this patient population.