Clinical scenario

A middle-aged patient with a history of Tetralogy of Fallot repair (status post modified Blalock-Taussig shunt, right ventricular outlet tract reconstruction and ventricular septal defect repair, with more recent pulmonary artery patch annuloplasty with dilation and stenting, pulmonary valve replacement and aortic valve and root replacement) and symptomatic atrial tachycardia on coumadin therapy presented to an outside institution with dyspnoea and recurrent atrial fibrillation. The patient underwent CT pulmonary angiogram (CTPA), which demonstrated multiple unopacified areas in the bilateral segmental pulmonary artery branches; however, international normalised ratio was supratherapeutic at 4.1. The patient was transferred to our facility for suspected pulmonary emboli (PE). On assessment, the patient was noted to be in atrial fibrillation without evidence of hypoxia or respiratory compromise. In the context of adequate anticoagulation and a lack of clinical …