https://orcid.org/0000-0003-0294-6732
A 65-year-old man with history of chronic thromboembolic pulmonary hypertension underwent balloon pulmonary angioplasty (BPA) combined with rivaroxaban 15 mg once daily. Lung ventilation/perfusion scintigraphy using 81mKrypton and 99mTechnetium showed multiple segmental and sub-segmental mismatched perfusion defects (Panels A and B), and pulmonary artery angiography (PAG) at the time of diagnosis showed irregular vessel contour and occlusion which localized in segmental and sub-segmental pulmonary artery (Panels C and D, see Supplementary material online, Videos S1 and S2). After several times of interventions, segmental PAG showed improved flows, and the mean pulmonary artery pressure (PAP) was improved from 31 to 25 mmHg along with his symptoms improvement. However, the patient felt gradually worsening dyspnoea on exertion after discharge, and PAG 3 months after BPA showed the filling defect in left A10 pulmonary artery branches (Panel E; see Supplementary material online, Video S3). As mass in the pulmonary artery was pathologically thrombus without malignancy, he took intravenous unfractionated heparin and then switched to vitamin K antagonist (VKA) combined with riociguat. Five months after VKA treatment with a target prothrombin time-international normalized ratio of 2–3, restudy of PAG revealed improved blood flow with no apparent thrombus (Panel F; see Supplementary material online, Video S4), and mean PAP was improved to 17 mmHg without any associated symptoms. He remained stable for 1.5 years after discharge. This case illustrates recurrent pulmonary thrombosis after BPA treated with direct oral anticoagulant (DOAC), and switching medication from DOAC to VKA improved pulmonary artery flow with banishing massive thrombus.
Supplementary material is available at European Heart Journal online.
The data underlying this article are available in the article and in its online Supplementary material.
The patient has given his permission for us to publish these features of the patient’s case.
