Multisite thrombosis and cor pulmonale in an infant treated with surgical embolectomy: a case report

Venous thromboembolism with saddle pulmonary embolus is associated with high mortality in infants and is exceedingly rare, particularly in patients without a known predisposition to hypercoagulability. Prompt diagnosis followed by surgical intervention can lead to survival with excellent outcome. An otherwise healthy 13-month-old female presented with recent upper respiratory symptoms and seizure-like activity that may have represented gastroesophageal reflux, breath-holding spells, a brief resolved unexplained event, or another non-epileptic event. The acute onset of vomiting and hypotension prompted further workup including an abdominal ultrasound that identified thrombus within the inferior vena cava. Computed tomography angiography revealed a massive saddle pulmonary embolism, and right heart failure (cor pulmonale) was confirmed by echocardiography. The patient was anticoagulated with heparin, transferred to a higher level of care for cardiac surgical services, and due to hemodynamic deterioration underwent emergent surgical pulmonary embolectomy with inferior vena cava and hepatic vein embolectomy with complete recovery. A predisposing thrombotic condition has not been identified, and dehydration associated with a recent presumed vial illness was considered a potential contributing factor, although a definitive etiology was not identified. This report describes an unusual, life-threatening presentation of extensive multisite thrombosis of unclear etiology in an infant. Pulmonary embolus should be considered in the differential diagnosis for infants in shock, as prompt diagnosis and cardiac surgery can be lifesaving. Here, an efficient surgical approach resulted in an excellent outcome.