Case study 2

A case of “failure to recover” from pulmonary embolism (PE)

Jack is a 56-year-old orthodontist with a history of deep vein thrombosis (DVT) 12 years ago.

• He was treated with anticoagulation for 3 months

• 8 years ago, Jack developed an acute pulmonary embolism (PE) after a long flight

• Jack was started on anticoagulation subsequent to the PE, and he has been on it ever since

Jack’s HCP notes that Jack never completely “recovered” from the PE.

• He has persistent exercise intolerance

• Occasional palpitations and chest pressure—but no syncope

• His father had DVT; otherwise, no meaningful family history

Jack’s past medical history includes systemic hypertension and mild arthritis.

• He’s on an ACE inhibitor, warfarin, and a beta blocker

• 16 years ago, he had a knee arthroscopy but has had no other surgeries

On physical exam, Jack appeared generally well.

• His lungs were clear, though a murmur was heard over the left posterior lung field

• His heart showed a II/VI holosystolic murmur along the left lower sternal border and a somewhat loud P₂

• He had no edema or clubbing

On referral, initial evaluation of Jack revealed the following:

• Chest x-ray showed mild cardiomegaly and clear lungs

• Chest CT showed mosaic perfusion and potential irregularities of the right descending pulmonary artery; no luminal filling defects were evident

• Echocardiogram showed moderate right ventricular (RV) enlargement and dysfunction

• RV systolic pressure was estimated to be 64 + right atrial pressure

Segmental map