Navigating Acute Pulmonary Embolism With Dilated Cardiomyopathy and Multisite Thrombosis

A 60-year-old woman presented with intermittent chest discomfort for 1 month, which had worsened over the preceding week and was accompanied by progressive dyspnea. Her medical history was notable for hepatitis approximately 40 years earlier. On admission, physical examination revealed jugular venous distention, cardiomegaly, and bilateral pitting edema of the lower extremities. Laboratory testing showed an NT-proBNP level of 8,272 pg/mL and a d-dimer level of 7,948 ng/mL. Computed tomography pulmonary angiography (CTPA) revealed bilateral thrombi in the main pulmonary arteries. Transthoracic echocardiography showed marked biventricular enlargement (LVEF 20%), 2 mural thrombi in the left ventricle, and a mobile thrombus in the right atrium. Lower extremity venous ultrasonography demonstrated deep vein thrombosis. Genetic testing using a cardiomyopathy gene panel identified a likely pathogenic TTN truncating variant (c.6061C>T, p.Arg2021*), consistent with the patient's phenotype of dilated cardiomyopathy (DCM). In conclusion, this case highlights the complex management of acute pulmonary embolism (PE) complicated by severe heart failure, multisite thrombosis, and acute hepatic congestion, emphasizing the critical need for individualized anticoagulation bridging and early adjunctive mechanical interventions.