Point-of-Care Ultrasound in the Diagnosis of Pulmonary Embolism With Right Heart Strain: A Case Report of Dialysis Line-Related Complications

Pulmonary embolism (PE) represents a significant cause of preventable death among critically ill patients, with the immediate diagnosis impaired by the presence of hemodynamic compromise and limited access to advanced imaging. Point-of-care ultrasound (POCUS) is a rapid bedside tool for diagnosing right heart strain, which can aid in immediate clinical management. Here we report a case of a 57-year-old man with end-stage renal disease who was on hemodialysis through a Hemodialysis Reliable Outflow (HeRO) graft and presented with acute hypoxia and cardiovascular collapse after recent orthopedic surgery. Bedside POCUS showed a dilated, hypokinetic right ventricle and a mobile echogenic mass adjacent to the tricuspid valve, concerning for thrombus and device-related PE. Due to the subsequent hemodynamic instability, systemic thrombolysis was performed during cardiac arrest with return of spontaneous circulation. Follow-up CT pulmonary angiogram revealed extensive bilateral PE with right heart strain, and transesophageal echocardiography (TEE) showed the HeRO graft tip abutting the tricuspid valve with no evidence of thrombus attached to the tricuspid valve. Following a multidisciplinary discussion, the HeRO graft was removed, and therapeutic anticoagulation was initiated, resulting in complete resolution. This case highlights the life-saving role of POCUS in promptly screening and guiding the emergent management of PE when standard imaging is unavailable. It also demonstrates an uncommon but potentially life-threatening HeRO graft-related complication: intracardiac thrombus formation with PE, and its features emphasize the importance of heightened clinical suspicion and a multidisciplinary approach for such patients.