2019 Scientific Sessions

Title ULTRASOUND-ASSISTED CATHETER DIRECTED THROMBOLYSIS OF SADDLE PULMONARY EMBOLI AND MASSIVE RIGHT ATRIAL THROMBUS IN A PATIENT WITH SALMONELLOSIS Introduction The thrombogenic potential of salmonellosis was first described by Verlin et al. in 1987. The proposed mechanism for thrombosis involves inflammation triggering thrombosis within vessels by ligation of the CLEC-2 receptors on platelets. There are only a few cases in the literature describing patients with salmonellosis complicated by thrombosis. We describe the novel use of ultrasound-assisted catheter directed thrombolysis (UACDT) in a case of a patient with salmonellosis complicated by saddle pulmonary embolism (PE) and massive right atrial thrombus. Clinical Case A 67-year-old chronically ill male with a medical history of hypertension presented to the hospital with diarrhea and fatigue for 1 week. The patient was afebrile with a blood pressure of 122/80 mmHg, heart rate of 96 bpm, and an oxygen saturation of 98% on room air. His workup was unrevealing with exception of an anion gap metabolic acidosis. On cardiovascular exam, he had a normal S1 and S2 without any appreciable murmurs, rubs or gallops. He improved clinically after aggressive intravenous hydration and supportive care for his diarrhea. His infectious workup later revealed non-typhoidal salmonella as the etiology of his gastrointestinal symptoms. On day 3 of hospitalization, the patient experienced a witnessed syncopal episode while having a bowel movement that was determined to be vasovagal in etiology. Subsequently on day 5, the patient’s platelet count dropped from 256 on admission to 68, and upon ambulation that day, the patient became suddenly tachycardic and hypotensive. Given his acute decline, he was transferred to the medical intensive care unit. CT angiography of his chest showed a large saddle embolism extending bilaterally into the right and left pulmonary arteries with an RV:LV ratio measured to be > 2 (Figure 1). A transthoracic echocardiogram showed a Left Ventricular ejection fraction (EF) of 50% with a massive freely mobile mass occupying > 50% of the right atrium at high risk of embolization (Figure 2). Given the new onset of thrombocytopenia, there was a high clinical suspicion for heparin induced thrombocytopenia (HIT). An Argatroban infusion was started and use of UACDT was recommended to reduce clot burden given the high risk of embolization of the right atrial mass. Discussion Literature describing the use of non-heparin anticoagulation with UACDT in setting of saddle pulmonary emboli is limited. There was concern that concomitant use of Argatroban and tissue plasminogen activator (tPA) would increase risk of bleeding. The decision was made to insert ultrasound-assisted bilateral pulmonary artery catheters through which tPA was infused over 12-hours. Follow-up echocardiogram 18 hours post-procedure revealed resolution of the massive right atrial thrombus, improvement of RV dysfunction and a small residual right ventricular thrombus. A few cases have been reported in the literature associating salmonellosis with vascular thrombosis. We described the novel use of UACDT with Argatroban and tPA in a case of a patient with salmonellosis complicated by extensive thrombus burden.