Review of echocardiographically diagnosed right heart entrapment of pulmonary emboli-in-transit with emphasis on management

Prevalence, Outcome, and Optimal Management of Free-Floating Right Heart Thrombi in the Context of Pulmonary Embolism, a Systematic Review and Meta-Analysis

Free-floating right-heart thrombus (FFRHT) in the context of a pulmonary embolism (PE) is a rare but serious encounter with no guidelines addressing its management. We performed a systematic review and meta-analysis addressing prevalence, clinical behavior, and outcomes of FFRHT associated with PE. Among the included 397 patients with FFRHT and PE, dyspnea was the main presenting symptom (73.3%). Obstructive shock was documented in 48.9% of cases. Treatment with thrombolytic therapy, surgical thrombectomy, and percutaneous thrombectomy was documented in 43.8%, 32.7%, and 6.5% of patients, respectively. The overall mortality rate was 20.4%. Syncope ( p: 0.027), chest pain ( p: 0.006), and obstructive shock ( p: 0.037) were significantly associated with mortality. Use of thrombolytic therapy was significantly associated with survival ( p: 0.008). A multivariate logistic regression model to determine mortality predictors revealed that syncope (OR: 1.97, 95% CI: 1.06–3.65, p: 0.03), and obstructive shock (OR: 2.23, 95% CI: 1.20–4.14, p: 0.01) were associated with increased death odds. Treatment with thrombolytic therapy (OR: 0.22, 95% CI: 0.086–0.57, p: 0.002) or surgical thrombectomy (OR: 0.35, 95% CI: 0.137–0.9, p: 0.03) were associated with reduced death odds. Meta-analysis of observational studies revealed a pooled prevalence of FFRHT among all PE cases of 8.1%, and overall mortality of 23%. Although uncommon, the presence of FFRHT in the context of PE is associated with high obstructive shock and mortality rates. Favorable survival odds are observed with thrombolytic therapy and surgical thrombectomy. Data are derived from case reports and observational studies. Clinical trials elucidating these findings are needed.

Right Atrial Thrombi, the Management Conundrum: 2 Case Reports

Case series

Patients: Male, 62-year-old • Male, 66-year-old

Final Diagnosis: Right atrial floating thrombus • right heart thrombus-in-transit

Symptoms: Shortness of breath

Medication: —

Clinical Procedure: —

Specialty: Cardiology

Impending Paradoxical Embolism: Perioperative Management and Role of Transesophageal Echocardiography

Impending paradoxical embolism is a rare but potentially life-threatening complication of venous thromboembolism that is usually associated with acute pulmonary embolism and a right to left atrial shunt. Patients may have associated right ventricular pressure or volume overload with subsequent failure. Transesophageal echocardiography is the preferred diagnostic test of choice in this patient group. Definitive management has yet to be clearly defined. However, emergent surgical removal of the entrapped intracardiac blood thrombus may be necessary. In this article, we review a case of impending paradoxical embolism managed surgically and describe the perioperative anesthetic considerations in this patient population, along with the role of intraoperative transesophageal echocardiography.

Special Considerations in Pulmonary Embolism: Clot-in-Transit and Incidental Pulmonary Embolism

This article describes 2 relatively rare, but complex situations in pulmonary embolism (PE): clot-in-transit (CIT), incidental PE (IPE). CIT describes a venous thromboembolism that has become lodged in the right heart. CIT is associated with high mortality and presents unique challenges in management. Incidental PE (IPE) describes PE diagnosed on imaging performed for another indication. The treatment is complex because there is often a disconnect between the PE severity on imaging and lack of severity of the clinical presentation. We summarize the available literature and aid clinicians as they manage patients with PE across the clinical severity spectrum.

Rapid evaluation of acute pulmonary embolism with thromboembolism-in-transit

We report a case of thromboembolism-in-transit through a patent foramen ovale that could cause systemic embolism in a patient with pulmonary embolism. An accurate and quick diagnosis by transthoracic echocardiography and computed tomography allowed emergent surgical thromboembolectomy to be performed without complications. Integral diagnostic workup should be performed in case of acute pulmonary thromboembolism whether the patient is hemodynamically stable or not.

Floating right heart thrombi: A pooled analysis of cases reported over the past 10years

INTRODUCTION

Floating right heart thrombi (FRHTS) are a rare phenomenon associated with high mortality. Immediate treatment is mandatory, but optimal therapy is controversial.

OBJECTIVE

To compare the clinical characteristics according to different treatment strategies and to identify predictors of mortality on patients with FRHTS.

METHODS

We conducted a systematic search of reported clinical cases of TTRH from 2006 to 2016.

RESULTS

207 patients were analyzed, median age was 60years, 51.7% were men, 31.4% presented with shock. Pulmonary thromboembolism was present in 85% of the cases. The treatments administered were anticoagulation therapy in 44 patients (21.28%), surgical embolectomy in 89 patients (43%), thrombolytic therapy in 66 patients (31.8%), percutaneous thrombectomy in 3 patients (1.93%) and fibrinolytic in situ in 4 (1.45%). The overall mortality rate was 21.3%. The mortality associated with anticoagulation alone was higher than surgical embolectomy or thrombolysis (36.4 vs 18% vs 18.2%, respectively, p=0.03), and in percutaneous thrombectomy and fibrinolytics in situ was 0%. At multivariate analysis, only anticoagulation alone (odds ratio [OR] 2.4, IC 95% 1.07-5.4, p=0.03), and shock (OR 2.87 (IC 95% 1.3-5.9, p=0.005) showed a statistically significant effect on mortality.

CONCLUSION

FRHTS represent a serious form of thromboembolism that requires rapid decisions to improve the survival. Anticoagulation as the only strategy does not seem to be sufficient, while thrombolysis and surgical thrombectomy show better and similar results. A proper individualization of the risk and benefits of both techniques is necessary to choose the most appropriate strategy for our patients.

Clot in Lung, Clot in Heart: A Case Report of Tumor-Like Thrombus in Right Atrium

Tumor-like formation of thrombus in the right atrial cavity is rare. It may be mistaken for a myxoma. The exact pathophysiology of an isolated thrombus in the heart is still unclear. Management to prevent complications such as pulmonary thromboembolism depends on the clinical judgment of a cardiologist. This report describes a 76-year-old woman with right atrial thrombus causing subsequent pulmonary thromboembolism in right lung. She initially presented to us with pulmonary embolism, and later, an incidental finding of a mass in her right atrium revealed an association of thrombus in heart with thrombus in lung. The challenging management was to resect this thrombus which was fixed to atrial septum, and a trial of anticoagulation did not resolve it. Exact management of such incidental findings in right heart cavities is not well established. Some cases may benefit from resection of such formed fixed thrombus.

Comparative efficacy of different modalities for treatment of right heart thrombi in transit: a pooled analysis

The objective was to compare the efficacy of treatment options for right heart thrombi (RHT) in transit. All published reports between 1992 and 2013 were identified and pooled. We analyzed 328 patients with RHT and pulmonary embolism (PE). The treatments administered were none in 11 patients (3.4%), anticoagulation (AC) with heparin in 70 patients (21.3%), thrombolytics in 122 patients (37.2%), catheter-related treatments in five patients (1.5%) and surgical embolectomy in 120 patients (36.6%). The overall short-term mortality for the entire cohort was 23.2%. The mortality rate associated with no therapy was highest at 90.9%. The mortality associated with AC alone was significantly higher than surgical embolectomy or thrombolysis (37.1% vs 18.3% vs 13.7%, respectively). In univariate analysis, any therapy was better than no therapy with a favorable odds of 16.92 (95% CI 2.05-139.87) for AC, 61.76 (95% CI 7.42-513.81) for thrombolysis and 44.54 (95% CI 5.42-366.32) for surgical embolectomy. In multivariate analysis with age and hemodynamic status entered as covariates, thrombolytic therapy was better than AC with favorable odds of 4.83 (95% CI 1.52-15.36). Similarly, there was a trend in favor of surgical embolectomy with an odds of 2.61 (95% CI 0.90-7.58). The estimated probability of survival in hemodynamically unstable patients with AC, surgical embolectomy and thrombolysis was 47.7%, 70.45% and 81.5%, respectively. There was no significantly increased risk of complications with thrombolytic therapy. In conclusion, left untreated, patients with RHT and PE have very high mortality. Aggressive management with thrombolysis or surgical thrombectomy may be more effective than AC alone in the management of these patients.

Clinical and echocardiographic diagnosis, follow up and management of right-sided cardiac thrombi

BACKGROUND

Right-sided cardiac masses are infrequent and have varied clinical presentation. The present study describes the clinical features, echocardiographic findings and management of 19 patients presenting with right-sided cardiac thrombi in a tertiary care center in north India.

METHODS

This is a retrospective, single center observational study of consecutive patients over the period January 2003-2008 admitted in our emergency intensive care unit (EICU). We identified 38 patients with right-sided cardiac masses admitted to EICU diagnosed by transthoracic echocardiography of which 19 patients had right-sided thrombus. The echocardiographic findings were reviewed by two cardiologists in all patients. Treatment was not standardized and choice of therapy was based on judgment of attending physician.

RESULTS

The mean age of patients with cardiac thrombus was 36.6 ± 11.8 years. Right atrial (n = 17) and right ventricle (n = 2) thrombi were associated with deep vein thrombosis (DVT) in 7 (36.8%) and pulmonary embolism in 3 (15%) patients. 13 (68.4%) patients appeared to have in situ mural thrombus. 12 patients were managed with oral anticoagulants, 3 patients underwent surgery and 4 patients were thrombolysed. All the survivors had a mean follow-up of 40 ± 6 months (range--18-50 months).

CONCLUSIONS

Prompt echocardiographic examination in an appropriate clinical setting facilitates faster diagnosis and management of patients with right-sided cardiac thrombi. High incidence of in situ mural thrombus and varied comorbidities predisposing to right-sided cardiac thrombi besides DVT and pulmonary embolism need to be recognized. Oral anticoagulation and thrombolysis appear to be the mainstay of treatment with surgery limited for selected patients.

Successful multiple-step management of intravenous leiomyomatosis diagnosed after episode of acute abdominal pain: Case report and review of literature

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Intravenous leiomyomatosis could be defined as the extrauterine extension of smooth-muscle cells.

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IVL causes systematic complications and is characterized by increased possibility of recurrence.

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Diagnosis is an issue of high clinical difficulty.

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Surgical resection of IVL either in one or in multiple-step strategy remains the optimal approach.

Introduction

We present the case of a 37-year old woman diagnosed with intravenous leiomyomatosis (IVL) that was managed uneventfully with multiple-step management.

Presentation of case

A 37-year-old woman was admitted because of acute abdominal pain. Emergency Computed Tomography demonstrated a big pelvic mass 5 × 15 cm of heterogenous composition intaking the contrast agent. Total hysterectomy with salpingoophorectomy was proposed to patient, however, patient expressed her will for fertility preservation and gave consent only for the resection of a single ovary. Laparotomy revealed the presence of myoma, multiple lesions of potential adenomyosis and cordon-shaped formations arising from uterus and extending mainly to left ovary. Final histological diagnosis was intravenous leiomyomatosis (IVL). MRI angiography revealed the presence of residual lesions in inferior vena cava. Laparoscopic resection was performed one month after laparotomy and left ovary was resected without complications. Venovenous bypass was finally performed three months later from initial surgery. The process was significantly labored, resulted in the successful resection of intravenous lesions but was complicated intraoperatively by right kidney rupture. After a follow-up of 33 months, case remains uncomplicated without signs or symptoms of potential recurrence.

Discussion

Intravenous leiomyomatosis represents a rare clinical entity histologically bening but clinically aggressive. No consensus exists regarding the optimal management, especially in cases with initial will for fertility preservation.

Conclusion

IVL represents a rare clinical entity often presenting difficulties in diagnosis and optimal treatment. Large case-series studies should be encouraged to assess the optimal management.

Intra-arrest formation of right-heart thrombi -- a case illustrated by real-time ultrasonography

The presence of free-floating right-heart thrombus has been reported in a cardiac arrest patient in the periarrest period. Free-floating right atrial thrombus is a rare phenomenon seen in patients developing severe pulmonary embolism, and is associated with increased mortality. However, there have been no previously reported cases of right-heart thrombus formation during a resuscitated cardiac arrest. We present the pre-hospital case of a woman in the clinical setting of cardiogenic shock due to acute myocardial infarction who developed asystolic cardiac arrest on the scene. Recent implementation of ultrasonography into the regional pre-hospital care protocol enabled sonographic investigation before and during cardiac arrest. This allowed detection of right atrial septal thrombus formation in the course of advanced life support and its migration through the tricuspid valve. The pathophysiological consequences, clinical significance and potential therapeutic options are discussed.

Tricuspid valve thrombus causing acute pulmonary embolism

The development of thrombus on the tricuspid valve is very rare in adulthood and it needs special attention in clinical practice as it can be confused with vegetation or a tumour. Embolisation due to thrombus may have an acute and unexpected course with a detrimental prognosis and a high death rate during the first 24 h after diagnosis. In this report, we presented a case of mobile tricuspid valve thrombus detected by transthoracic echocardiography that led to recurrent pulmonary embolism.

Abrupt formation of a right atrium thrombus detected by transesophageal echocardiography during laparoscopic assisted vaginal hysterectomy and spontaneous resolution during thromboembolectomy -A case report-

Intraoperative formation and management of a thrombus in right atrium has been reported occasionally. Nevertheless, it is rare that a right atrial thrombus with unstable hemodynamic changes detected by transesophageal echocardiography is resolved spontaneously. We report upon the 44-year-old woman, who had a right atrial thrombus detected by transesophageal echocardiography during laparoscopic assisted vaginal hysterectomy and resolved during thromboembolectomy.

Paradoxical embolus caught in transit through a patent foramen ovale

Diagnosing a paradoxical embolism is challenging, and it can be proven only if the thrombus is identified across the intracardiac defect. Very few cases have been diagnosed as an impending paradoxical embolism. Recently, the diagnosis and management of these entities have greatly improved with the advent of transesophageal echocardiography (compared with transthoracic echocardiography). Pulmonary hypertension may cause right-to-left shunting across a patent foramen ovale and predispose development of a paradoxical embolism. We report a patient with an impending paradoxical embolism that was caught in transit across the patent foramen ovale. The patient was treated successfully with emergent surgery.

Successful thrombolytic therapy with recombinant tissue-type plasminogen activator for massive pulmonary embolism -A case report-

Massive pulmonary embolism is associated with significant perioperative morbidity and mortality. We report here on a case of a 69-year-old man who suffered a massive pulmonary embolism with pulseless electrical activity during knee arthroscopic surgery. After a diagnosis was made by performing transthoracic echocardiography, the patient was treated with recombinant tissue-type plasminogen activator. The patient was transferred to the intensive care unit after his hemodynamic status improved. The patient went on to make a full cardiopulmonary recovery without any complications.

Abrupt formation and spontaneous resolution of a right atrial thrombus detected by intraoperative transesophageal echocardiography during replacement of an abdominal aortic aneurysm

Intraoperative formation of a thrombus in the right atrium and its management has occasionally been reported. However, spontaneous resolution of right atrial thrombi, without any event, is rare. We report a case of abrupt right atrial thrombus formation and spontaneous resolution, with no events, detected by transesophageal echocardiography during the replacement of an abdominal aortic aneurysm.

Right cardiac thrombus in transit among patients with pulmonary thromboemboli

BACKGROUND

This study was designed to investigate the prevalence, clinical and laboratory findings, and short-term prognostic significance of mobile right cardiac thrombus (MRCT) among patients with pulmonary thromboembolism (PTE).

METHODS

From January 2004 to November 2006, 12 of 100 patients admitted with a diagnosis of PTE had an MRCT. Diagnosis of in-transit right-sided thrombi was made when a wormlike elongated mass was detected. The primary end point was comparison of the mortality rate of MRCT (+) patients with that of MRCT (-) patients for an average of 8 months of follow-up. The secondary end points were comparison of clinical and laboratory data between these 2 groups.

RESULTS

All MRCT (+) patients but 1 had dyspnea, but just 2 patients had syncope during exertion. The most frequent electrocardiographic finding was T inversion in leads V1-V3 (75%). All 6 of the MRCT (+) patients who had a cardiac arrest in the hospital died in the hospital. In comparison, of the 88 MRCT (-) patients, 12 had a cardiorespiratory arrest, 4 of whom survived (hospital mortality rate of 50% versus 9%, respectively).

CONCLUSIONS

It seems that the presence of MRCT has prognostic significance, predicting a higher-than-average mortality rate.

Thrombolysis of mobile right atrial thrombi following severe pulmonary embolism

Thrombolysis may favorably affect the clinical outcome of mobile right atrial thrombus following pulmonary embolism (PE). We report the case of three patients with mobile right atrial thrombus following PE, in whom fibrinolysis was performed. Atrial mass disappeared on the control echocardiogram, but control ventilation perfusion scan showed new perfusion defects in all patients. Thrombolysis seems successful for the treatment of patients with mobile right atrial thrombus following PE; however, recurrent PE may be induced by fibrinolysis. This may affect the benefit of such therapy and should be taken into account when using this therapeutic treatment.

A critical review of thromboembolic complications associated with central venous catheters

PURPOSE

Central venous catheters (CVC) are commonly used in critical care. While thrombosis is a well-recognized and frequent complication associated with their use, CVC-related thromboembolic complications, including pulmonary embolism (PE) and right heart thromboembolism (RHTE), occur less frequently and often evade diagnosis. Little information exists to guide clinicians in the diagnosis and management of CVC-related thromboembolic complications.

SOURCE

We critically review and synthesize the literature highlighting the incidence of CVC-related thrombosis. We highlight the risk for developing thromboembolic complications and provide approaches to diagnosing and managing RHTE.

PRINCIPLE FINDINGS

The incidence of CVC-related thrombosis varies depending on patient, site, instrument, and infusate-related factors. Central venous catheters-related thrombosis represents an important source of morbidity and mortality for affected patients. Pulmonary embolism occurs in approximately 15% of patients with CVC-related upper extremity deep venous thrombosis (UEDVT). More frequent use of transesophageal echocardiography, in patients with suspected and confirmed PE, has resulted in increased detection of RHTE. While it is recognized that the occurrence of RHTE, in association with PE, increases mortality, the optimal strategy for their management has not been established in a clinical trial.

CONCLUSION

Central venous catheter-related thrombosis occurs frequently and represents an important source of morbidity and mortality for affected patients. Our review supports that surgery and thrombolysis have both been demonstrated to enhance survival in patients with RHTE and PE. However, important patient, clot, and institutional considerations mandate that treatment for patients with RHTE and PE be individualized.

[Disseminated arterial occlusions revealing bilateral venous thrombosis with paradoxical embolisms]

Paradoxical embolism is a diagnosis of exclusion. Clinical triad associates deep venous thrombosis with or without pulmonary embolism, arterial embolism, and intracardiac communication with right-to-left shunt. The intracardiac communication is generally related to a patent foramen ovale (PFO). We report a 75-year-old patient, who presented with bilateral deep venous thrombosis of the legs, complicated by massive pulmonary embolism and paradoxical embolisms through a PFO. This resulted in cerebral, mesenteric, splenic and bilateral kidney infarctions. A promptly initiated anticoagulant treatment allowed a favourable outcome.

Recurrent intracardiac leiomyomatosis

An intravenous leiomyoma, a histologically benign smooth muscle tumour, arises from either a uterine myoma or the walls of a uterine vessel, with extension into veins. The present report describes echocardiographic features of an intravenous leiomyoma that spread into the right-sided cardiac chambers in a middle-aged woman who had undergone a hysterectomy two years earlier. Echocardiographic features included an elongated mobile mass extending from the inferior vena cava and multiple masses in the right atrium and right ventricle. Intracardiac leiomyomatosis should be considered in women who present with a cardiac mass in the right-sided chambers.

Is right heart thromboemboli another indication for thrombolysis?

Pulmonary embolism (PE) is a common and a potentially life-threatening disease. Diagnosis is challenging because the signs and symptoms are non-specific. Moreover treatment of PE is shrouded in controversy. Even at presentation the role of thrombolysis in managing patients with PE remains unclear. In those patients with right heart thromboemboli, thrombolysis is usually suggested, but the evidence remains unclear. We report a 34-year-old man who was diagnosed with right heart thromboemboli on echocardiography and was successfully managed with thrombolysis and anticoagulation. We also review the current published work on the management of patients with right heart thromboemboli.

CASE REPORTS: Intracardiac Thrombosis in Multiple Chambers and Descending Aorta Manifested as Systemic and Pulmonary Thromboembolism

We report a case with multiple thrombosis that underwent sudden circulatory collapse due to acute pulmonary embolism and ischemic stroke. Further confirmed by transesophageal echocardiography, the thrombus in both atria was detected by transthoracic echocardiography. In addition, patent foramen ovale and another thrombus in the descending aorta were readily identified by transesophageal echocardiography. Aspirin was prescribed and thrombi disappeared 1 month later. Our case report suggests that patients undergoing sudden collapse with unexplained hypoxemia and new neurological deficit secondary to coexistence of pulmonary and systemic embolism should be promptly evaluated by echocardiography, especially transesophageal one, with high suspicion for paradoxical embolism.

Mobile thrombi of the right heart in pulmonary embolism: delayed disappearance after thrombolytic treatment

BACKGROUND AND OBJECTIVE

In patients presenting with pulmonary embolism (PE), echocardiography, in some cases, reveals mobile clots in right heart (RH) cavities. How these clots evolve after treatment, in particular after thrombolytic treatment (TT), is unknown. We sought to determine the outcome of these mobile clots in the RH during TT.

METHODS AND RESULTS

Of a series of 343 patients who had been hospitalized for PE in our department, echocardiography performed on hospital admittance showed a mobile clot in the RH in 18 patients (mobile clot incidence, 5.2%). This subgroup of 18 patients presented with a more severe form of PE than the 325 patients without mobile clots in the RH. In our series, 16 patients were treated with thrombolytic agents. Close echocardiography monitoring showed the outcomes of these mobile clots during and after TT. In 50% of cases, the clot disappeared rapidly in < 2 h after the end of TT. In 50% of the remaining cases, the clot disappeared later, half within 12 h following the completion of TT, and the other half within 24 h. All patients were alive on day 30 without any clinical sequellae.

CONCLUSION

In these particular forms of PE with mobile clots in the RH, the short time lag required to disperse the clot after TT makes it imperative to delay any decision about new aggressive therapy.

Management of mobile right heart thrombi: a prospective series

BACKGROUND

Mobile right heart thrombi (MRHT) are uncommon but their true prevalence is unknown. The aim of our study was to assess the prevalence of MRHT by a systemic use of transthoracic echocardiography in a prospective series of consecutive patients admitted for acute severe pulmonary embolism (PE) and to adopt intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) as the first line intention to treat patients with proven MRHT.

METHODS AND RESULTS

We performed a systematic transthoracic echocardiogram from November 1997 to June 1999 in 335 consecutive patients admitted for suspected acute massive PE in whom the diagnosis was subsequently confirmed by perfusion lung scan or angiography. MRHT was identified in 12 of the 335 patients (4%). Nine patients presented a coil form and three patients a ball form. The thrombolytic employed in all cases was rt-PA according to the following protocol: 10 mg in a bolus and 40 mg over 2 h, followed by 50 mg over 5 h, up in a total dose of 100 mg, associated with a bolus of 5000 units of heparin. Control echocardiograms were performed 12 h after the initiation of treatment and at 12-month follow-up. Three patients died before the onset of thrombolytic infusion. The nine remaining patients were submitted to thrombolytic therapy using rt-PA. In seven of the nine remaining patients, MRHT was no longer observed after 12 h and the echocardiographic signs of RV overload had disappeared. The two last patients required adjunctive surgery because of evidence of persistent thrombus in a pulmonary artery. After 24 h, both scintigraphy and angiography demonstrated improved pulmonary perfusion. At 1-year follow-up, all patients were alive and the pulmonary artery pressure estimated by Doppler echocardiography was <30 mm Hg.

CONCLUSIONS

The incidence of right heart thrombus is low in patients admitted for acute PE. Thrombolytic therapy with rt-PA appears to be rapidly effective in most patients with MRHT. The thrombus usually resolves and pulmonary perfusion is rapidly improved. Systematic echocardiogram appears to be useful for rapidly detecting MRHT in patients with suspected massive PE.

Anaesthetic considerations in a patient with right heart thrombi-in-transit

This is a case report of a patient with underlying pulmonary thromboembolism who was diagnosed as having a large, mobile right heart thrombi while undergoing treatment with low-molecular weight heparin. She underwent emergency embolectomy with exploration of the right heart under a cardiopulmonary bypass (CPB). Soon after induction of anaesthesia, the patient had an episode of severe hypotension, which responded to inotropes. Large, serpiginous thrombi were found in the right atrium extending into the right ventricle and pulmonary arteries, which were evacuated. She was weaned off CPB on inotropic support and was extubated uneventfully on the 4th POD. Postoperatively, she was started on anticoagulant therapy and also underwent placement of a Greenfield inferior vena caval (IVC) filter to prevent further thromboembolic episodes.

Two cases of complications of the thrombolysis of right heart free-floating thrombi with pulmonary embolism: important role of echocardiographically based management

We present two cases where successful thrombolysis of right heart thrombi and pulmonary embolism was accompanied by serious adverse events. In patient 1 with massive pulmonary thromboembolism, transesophageal ultrasound revealed large right atrial thrombus entrapped in a patent foramen ovale. Initial treatment with heparin was substituted with thrombolysis, which resulted in clinical improvement and dissolution of right heart thrombus but was followed by fatal intracerebral haemorrhage. In patient 2, thrombolysis caused mobilisation of thrombotic mass as evidenced by disappearance of thrombus on ultrasound. Massive pulmonary thromboembolism resulted in circulatory collapse. Short cardiopulmonary resuscitation restored spontaneous circulation and the patient recovered completely.

Embolus in transit

A patient who presented with recurrent syncopal episodes was discovered to have a right-sided heart mass, which was revealed as an embolus in transit resulting in a lethal pulmonary embolic event. The initial focus of etiology on tumor rather than thrombus was misleading. A higher index of suspicion of thrombus in right heart mass may help future patients receive more directed therapy.

Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry

OBJECTIVES

This study was designed to investigate the prevalence and prognostic significance of right heart thrombi (RHTh) in pulmonary embolism.

BACKGROUND

Most reports about patients with RHTh are small case series. We analyzed data referring to RHTh among 2,454 consecutive pulmonary embolism patients enrolled in the International Cooperative Pulmonary Embolism Registry.

METHODS

Of the 2,454 patients, 1,113 had results available from baseline echocardiography. We compared the 42 patients with RHTh versus 1,071 without RHTh.

RESULTS

Patients with RHTh had shorter duration of symptoms (2.2 +/- 2.9 days vs. 4.3 +/- 6.0 days, p = 0.013), lower systolic blood pressure (BP) (116.0 +/- 28.8 vs. 125.7 +/- 25.0 mm Hg, p = 0.008), and more frequent right ventricular hypokinesis (64% vs. 40%, p = 0.002) and congestive heart failure (26% vs. 13%, p = 0.024); but they had similar age (62.9 vs. 62.5 years), arterial oxygen pressure (71.3 +/- 26.0 vs. 69.5 +/- 30.5 mm Hg), and prevalence of cancer (14% vs. 19%). The overall mortality rate at 14 days and at three months was higher in patients with RHTh (21% vs. 11%, p = 0.032, and 29% vs. 16%, p = 0.036). The difference in early mortality was observed almost entirely within the subgroup of patients treated with heparin alone (23.5% vs. 8%, p = 0.02), despite similar clinical severity at presentation (systolic BP 122.2 +/- 24.2 vs. 127.8 +/- 24.1 mm Hg, hypotension in 5.9% vs. 3.4% patients).

CONCLUSIONS

Among patients with acute pulmonary embolism, RHTh is usually found in those more hemodynamically compromised but is also a marker of worse prognosis in initially apparently stable patients treated with heparin alone.

Diagnostic utility of echocardiography in patients with suspected pulmonary embolism

The aim of this study was to investigate the clinical utility of echocardiography in the diagnosis of pulmonary embolism (PE). For this, we enrolled 162 patients with suspected PE in a prospective study. We evaluated the sensitivity and specificity of right ventricular dilatation, the Doppler evidence of pulmonary hypertension, and their possible associations. We also calculated the number of lung-scan angiography procedures avoided and the number of patients unnecessarily treated when echocardiography was included in the diagnostic work-up. The sensitivity and specificity of echocardiography ranged between 29 and 52% and between 96% and 87%, respectively. Adding echocardiography to the diagnostic strategy for PE would avoid about 12 to 28% of lung-scan angiography procedures, but would cause inappropriate treatment of 4 to 14% of all treated patients. The clinical utility of echocardiography in the diagnosis of PE is limited. The reduction in the number of standard diagnostic procedures obtained through its use would be counterbalanced by an excess of patients inappropriately treated.

Local and systemic thrombolytic therapy for acute venous thromboembolism

Thrombolytic therapy unquestionably leads to more rapid and complete clot lysis with a significantly higher risk of bleeding when compared with anticoagulation. The most definite indication for thrombolytic therapy in patients with VTE is massive PE associated with hemodynamic instability. Other potential indications, although not widely accepted or proven, include PE-related respiratory failure with severe hypoxemia and massive iliofemoral thrombosis with the risk of phlegmasia cerulea dolens. Routine use of thrombolytic therapy in all other cases of PE and DVT cannot be justified. Future research using randomized controlled studies should focus on the following key questions: Do hemodynamically stable patients with PE and right ventricular dysfunction benefit from thrombolysis, and, if so, is there a subset of patients within this group who are most likely to benefit? Does thrombolytic therapy improve long-term outcomes of DVT with a favorable risk-to-benefit ratio, and, if so, which patients are most likely to benefit long-term? What is the precise role of catheter-directed thrombolysis in the treatment of VTE, particularly the use of a low-dose thrombolytic agent in conjunction with mechanical clot disruption to minimize bleeding in patients at high risk? Until these questions are answered, clinicians must approach decision-making regarding the use of thrombolytic therapy in PE and DVT with careful consideration of the potential risks and benefits for the patient within the framework of currently available data.

Eustachian valve thrombus:critical factor in outcome of venous thromboembolism

This case report describes a patient with pulmonary embolism (PE) in whom transesophageal echocardiography showed a thrombus in the right atrium attached to the eustachian valve (EV). The EV is typically absent in the adult, but when present it is considered to be benign. It is an uncommon site for thrombus formation. This patient was treated with systemic anticoagulation.

Principle mechanisms underlying venous thromboembolism: epidemiology, risk factors, pathophysiology and pathogenesis

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are distinct but related aspects of the same dynamic disease process known as venous thromboembolism (VTE). An estimated 200,000 new cases occur in the United States every year, including 94,000 with PE, resulting in an incidence of 23 per 100,000 patients per year-cases. Without treatment, pulmonary embolism is associated with a mortality rate of approximately 30%, causing nearly 50,000 deaths per year. Moreover, based on post-mortem studies, two-thirds of the patients with pulmonary emboli remain undiagnosed. Clinically, PE may present as (1) isolated dyspnea, (2) pleuritic pain and/or hemoptysis, and (3) circulatory collapse. However, clinical history and examination can be notoriously misleading in reaching a diagnosis. A number of acquired etiologic risk factors (predispositions) are associated with a tendency to develop VTE. These include increasing age, immobilization, surgery, trauma, hospital or nursing home confinement, malignancy, neurologic disease with extremity paresis, as well as certain types of oral contraception and hormone replacement therapy. In addition, a variety of genetic risk factors, such as factor V Leiden, protein S or C deficiency have also been identified. However, in at least half of the instances, no predisposing factors can be identified (idiopathic PE). In the majority of cases thromboemboli originate in the deep veins of the calf or pelvis. The pathogenic conditions for VTE comprise a triad of factors and include (1) venous stasis, (2) hypercoagulable states, and (3) vascular endothelium injury. Occlusion of pulmonary arteries has variable and transient clinical and pathophysiologic consequences, involving both mechanical and reflex effects of vascular occlusion with a consecutive perfusion defect as well as the release of vasoactive and other inflammatory mediators. The objectives of this article are to present an overview of the etiologic and pathogenic factors promoting VTE as well as the pathophysiologic and inflammatory processes following PE.