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BackgroundFor patients with acute pulmonary embolism (PE) diagnosed in the primary care setting, transfer to a higher level of care, like the emergency department, has long been the convention. Evidence is growing that outpatient management, that is, care without hospitalization, is safe, effective, and feasible for selected low-risk patients with acute PE. Whether outpatient care can be provided entirely in the primary care setting has not been well-studied. We report a case of outpatient management of a low-risk patient with acute PE without emergency department transfer.Case summaryA 74-year-old woman with a history of recent surgery and immobilization presented to a primary care physician with 10 days of mild, non-exertional pleuritic chest pain. Her D-dimer concentration was elevated. Computed tomography pulmonary angiography identified a lobar embolus without right ventricular dysfunction. She declined emergency department transfer but was classified as low risk (class II) on the PE Severity Index and met the criteria of the European Society of Cardiology (ESC) for outpatient care. Her physician provided comprehensive clinic-based PE management, discharging her to home with education, anticoagulation, and close follow-up. She completed her 3-month treatment course without complication.DiscussionThis case describes patient-centred, comprehensive, outpatient PE management in the primary care setting for a woman meeting explicit ESC outpatient criteria. This case illustrates the elements of care that clinics can put in place to facilitate PE management without having to transfer eligible low-risk patients to a higher level of care.

Background Pulmonary vein isolation (PVI) is becoming the therapy of choice for symptomatic paroxysmal drug-refractory atrial fibrillation (AF). The most frequently reported complications are vascular complications (1.4%). Bleeding complications of the central nervous system have rarely been described. We report a case of spontaneous spinal bleed after PVI. Case summary A 68-year-old woman with a 2-year history of highly symptomatic paroxysmal AF (EHRA 3) was referred for a PVI redo procedure. A high-density mapping showed pulmonary vein reconnection of all pulmonary veins successfully isolated by radiofrequency ablation. During the entire procedure, the patient had sinus rhythm with an ACT around 300 s. No intraprocedural and peri-procedural complications occurred. Four hours after haemostasis, the anticoagulation clotting time (ACT) was 110 s and rivaroxaban (20 mg) was reinitiated. In the following hours, the patient developed fluctuating neurological lower limb symptoms. A lumbar magnetic resonance imaging showed a subdural spinal haematic collection with an associated epidural component from L3 to S2 exerting compression over the dural sheath. A conservative treatment approach was adopted with progressive recovery of sensorial and motor deficits. After 5 months, the patient still presented residual lower limb motor deficits necessitating the support of a walking stick. Discussion We describe the first case of a spontaneous spinal bleeding following PVI. Given the gradual diffusion of PVI to treat AF in more clinically complex patients with a larger range of comorbidities, particular consideration should be given to seek predisposing bleeding factors in order to assess the risk for neurological complications.