Pulmonary embolism in a patient with mild factor VII deficiency after administration of recombinant activated factor VII during a urological procedure.

285 antibiotic therapy were initiated. A transthorac‐ ic echocardiography (TTE) showed significant right ventricular overload (right ventricular out‐ flow tract, 40 mm; right ventricular inflow tract [RVIT], 52 mm; tricuspid annular plane systolic excursion [TAPSE], 11 mm; severe tricuspid regur‐ gitation jet, 3.2 m/s). Because of high risk, the pa‐ tient was excluded from a surgery or an invasive procedure by a cardiothoracic surgeon. Alteplase, followed by heparin infusion, was administered, which in this case was a life ‐saving treatment and the only possibility left. Two hours later, a mas‐ sive bleeding from the urethral catheter occurred. The hemoglobin level decreased from 12.5 g/dl to 7.6 g/dl, and the patient was excluded from ur‐ gent surgery by a general surgeon. The heparin infusion was terminated. Then, 3 units of red blood cells were transfused and the heparin infu‐ sion was restarted. The patient’s condition stabi‐ lized after 3 days. The anticoagulant therapy was switched to enoxaparin, while dobutamine and adrenaline infusions were gradually tapered off and discontinued. A control TTE revealed signif‐ icant improvement in right ventricular function (RVIT, 40 mm; TAPSE, 24 mm; mild tricuspid re‐ gurgitation jet, 2.7 m/s), and the patient was dis‐ charged 10 days later. He was prescribed enoxa‐ parin (2 × 0.6 ml subcutaneously) for 3 months, torasemide (1 × 5 mg), perindopril (1 × 5 mg), and iron supplementation. A TTE performed after 3 months showed normal right ventricular func‐ tion (RVIT, 31 mm; TAPSE, 21 mm; mild tricus‐ pid regurgitation), and no symptoms of chronic thromboembolic pulmonary hypertension were observed. The current guidelines recommend rVIIa sup‐ plementation in patients with factor VII deficiency A 58 ‐year ‐old white man with a history of mild factor VII deficiency and superficial urinary blad‐ der cancer, treated with bacillus Calmette–Guérin therapy and transurethral tumor resection, was transferred from a urology department to our hospital due to pulmonary embolism (PE). In the past, the patient underwent several transure‐ thral mapping biopsies of the urinary bladder ac‐ cording to postoperative management protocol. Recombinant factor VII (rVIIa) as a prophylaxis of hemorrhage was used during each procedure. No history of hemorrhagic or thrombotic com‐ plications was revealed. Recently, the patient underwent urgent surgery at the urology department because of massive ex‐ traperitoneal bleeding after the latest transure‐ thral procedure, performed a week earlier. Dur‐ ing the surgery, rVIIa was administered again. The surgery was successful, without any local com‐ plications. On the fifth day after the procedure, the patient fainted. Because of persistent dys‐ pnea and hypoxia, PE was suspected. Comput‐ ed tomography angiography (FIGURE 1) was per‐ formed, revealing massive PE. On admission to our hospital, the patient was in cardiogenic shock. Oxygen saturation was 85% despite oxygen therapy, and blood pressure was 80/60 mm Hg during adrenaline infusion. The pa‐ tient’s Pulmonary Embolism Severity Index (PESI) score was 148 points, which corresponds to high‐ ‐risk PE (PESI class V).1 The D ‐dimer level ex‐ ceeded 34 690 ng/ml, the high ‐sensitivity tro‐ ponin level was 0.131 ng/ml, activated partial thromboplastin time index was 0.95 (reference range, 0.88–1.2), prothrombin time was 38 s (ref‐ erence range, 9.4–13.4 s), and international nor‐ malized ratio was 2.9. Dobutamine infusion and CLINICAL IMAGE