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Lane CM, Young KA, Norton MS, Bennett CE, Anavekar NS. Right Heart Thrombus in Transit on Point-of-Care Ultrasound: A Rare Finding with Key Management Repercussions. CASE 2022; 6:239-242. [PMID: 36036053 PMCID: PMC9399530 DOI: 10.1016/j.case.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Right heart thrombi are associated with high early mortality in PE. POCUS allows rapid assessment in hemodynamic compromise and suspected PE. Triple POCUS assessment of the lung, heart, and leg veins may improve PE detection.
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Affiliation(s)
- Conor M. Lane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kathleen A. Young
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark S. Norton
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Nandan S. Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Correspondence: Nandan S. Anavekar, MB, BCh, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
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2
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Thrombolysis of Postoperative Acute Pulmonary Embolism with a Thrombus in Transit. Case Rep Med 2020; 2020:7561986. [PMID: 32518563 PMCID: PMC7256686 DOI: 10.1155/2020/7561986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 04/14/2020] [Accepted: 05/01/2020] [Indexed: 11/18/2022] Open
Abstract
Right heart thrombus in transit clot (RHTT) associated with a pulmonary thromboembolism (PTE) is a rare but potentially fatal diagnosis. Early diagnosis and immediate intervention are crucial. This report describes the case of a healthy, physically active 32-year-old female who presented 19 days postoperatively, following an anterior cruciate ligament reconstruction and partial lateral meniscectomy with a saddle PE, RHTT, and right ventricular (RV) strain. The patient received half of the standard dose of intravenous tissue plasminogen activator (TPA) in combination with anticoagulation and survived. Case reports of RHTT will inform future studies designed to evaluate whether and when thrombolysis should be administered.
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3
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Alirezaei T, Aval ZA. Rescue thrombolysis partial failure in massive PE complicated with in-transit thrombus. Int Med Case Rep J 2019; 12:9-14. [PMID: 30666168 PMCID: PMC6330970 DOI: 10.2147/imcrj.s189944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A 58-year-old man who presented with syncope, dyspnea, and hemodynamic compromise was found to have large free-floating right atrial thrombuses on echocardiogram. Decision was made to transfer the patient for emergent atriotomy. Cardiothoracic surgeons declared the patient as inoperable and recommended to use a lytic agent. Alteplase was administered with subsequent near-complete resolution of symptoms and near-normalization of echocardio-graphic parameters. The post-thrombolytic course was complicated by saddle pulmonary emboli requiring embolectomy. Catheter embolectomy was not available and cardiothoracic surgeon in other center considered the patient to be very high risk for transferring between hospitals and surgical intervention. Ultimately, the critical decision was made, despite the patient having been administered thrombolytic therapy within the previous 48 hours. Alteplase was given, but was not effective and the patient required surgical intervention. Surgical embolectomy was done successfully in another hospital and the patient was discharged with warfarin.
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Affiliation(s)
- Toktam Alirezaei
- Cardiology Department of Shohaday-e-Tajrish Hospital, Shahid Behesti University of Medical Science, Tehran, Iran,
| | - Zahra Ansari Aval
- Cardiovascular Research Center, Shahid Behesti University of Medical Science, Tehran, Iran
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4
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Becattini C, Guglielmelli E, Floriani I, Morrone V, Caponi C, Pizzorno L, Masotti L, Bongarzoni A, Pignataro L, Casazza F. Prognostic significance of free-floating right heart thromboemboli in acute pulmonary embolism. Thromb Haemost 2017; 111:53-7. [DOI: 10.1160/th13-04-0303] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 08/28/2013] [Indexed: 11/05/2022]
Abstract
SummaryThe exact prevalence of mobile right heart thromboemboli (RHTh) in patients with pulmonary embolism (PE) is unknown, depending upon PE severity and the use of early echocardiography. Similarly, the mortality rate is variable, though RHTh detection appears to substantially increase the risk of death in patients with PE. The aim of this study was to assess the prevalence of RHTh in different risk categories in a wide series of patients with PE, and to analyse the effect of RHTh on in-hospital mortality. Among 1,716 patients enrolled in the Italian Pulmonary Embolism Registry, 1,275 (13.3% at high risk, 59.3% at intermediate risk and 27.4% at low risk) had echocardiography within 48 hours from hospital admission and entered the study. Overall, RHTh were detected in 57 patients (4.5%, at admission echocardiography in 88%): in 27/169 (16%) high-risk, in 29/756 (3.8%) intermediate-risk and 1/350 (0.3%) low-risk patients, respectively. At multivariate analysis, only advanced age (odds ratio [OR] 1.61, 95% confidence [CI] 1.27–2.03, p<0.0001), high-risk category (OR vs low-risk category 37.82, 95% CI 11.26–127.06, p<0.0001) and recurrent PE (OR 45.92, 95%CI 15.19–139.96, p<0.0001) showed a statistically significant effect on mortality. The presence of RHTh significantly increased the risk of dying (OR 3.89, 95%CI 1.98–7.67, p=0.0001) at univariate analysis, but this result was not mantained in the multivariate model (OR 1.64, 95%CI 0.75–3.60, p=0.216). In conclusion, though patients with RHTh had a more severe presentation of PE, this study did not detect an association between RHTh and prognosis.
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Pappas AJ, Knight SW, McLean KZ, Bork S, Kurz MC, Sawyer KN. Thrombus-in-Transit: A Case for a Multidisciplinary Hospital-Based Pulmonary Embolism System of Care. J Emerg Med 2016; 51:298-302. [DOI: 10.1016/j.jemermed.2016.05.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 04/30/2016] [Accepted: 05/06/2016] [Indexed: 12/27/2022]
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Orgeron GM, Pollard JL, Pourmalek P, Sloane PJ. Catheter-Directed Low-Dose Tissue Plasminogen Activator for Treatment of Right Atrial Thrombus Caused by a Central Venous Catheter. Pharmacotherapy 2016; 35:e153-8. [PMID: 26497485 DOI: 10.1002/phar.1645] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Catheter-related atrial thrombosis is a potentially deadly complication of central venous catheters. Options for treatment include surgical thrombectomy, systemic anticoagulation, and systemic thrombolysis, but the optimal method of treatment remains unknown. We describe a 48-year-old woman with a large right atrial thrombus who was successfully treated with localized recombinant tissue plasminogen activator (tPA). She was treated with an 18-hour infusion of localized low-dose tPA administered through her central venous catheter. The dimensions of the thrombus decreased from 30 × 16 × 22 mm to 10 × 8 × 5 mm after treatment with tPA, corresponding to an associated 96% reduction in thrombus volume. No major bleeding complications were observed. Catheter-directed thrombolysis provides the theoretical advantage of a decreased rate of major bleeding by reducing the exposure to and duration of high-dose systemic thrombolytic therapy. To our knowledge, this is the second case report describing the use of this novel therapy. Although no guidelines for the treatment of atrial thrombosis or consensus on the optimal regimen for catheter-directed thrombolysis (and intensity of concomitant anticoagulation) exist, we believe that this intervention may be a well-tolerated alternative to systemic thrombolysis and surgery in certain patients.
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Affiliation(s)
- Gabriela M Orgeron
- Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Jessica L Pollard
- Department of Pharmacy, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Paria Pourmalek
- Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland
| | - Peter J Sloane
- Department of Pulmonary and Critical Care Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland
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7
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Practical echocardiographic approach for risk stratification of patients with acute pulmonary embolism. J Echocardiogr 2016; 14:146-155. [PMID: 27510333 DOI: 10.1007/s12574-016-0306-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 07/08/2016] [Accepted: 07/28/2016] [Indexed: 01/21/2023]
Abstract
Acute pulmonary embolism remains a common cause of mortality. Early diagnosis and appropriate risk stratification is necessary to individualize treatment strategy. Computed tomography scan of the pulmonary arteries is routinely used to diagnose acute pulmonary embolism and in some cases is useful to assess right ventricular dilation. In patients with acute pulmonary embolism, right ventricular dilation and dysfunction indicates a high-risk situation where immediate administration of thrombolytic agent, catheter-directed thrombolysis, or surgical embolectomy could be considered. A bedside 2D echocardiogram at the time of presentation could provide additional morphological, functional, and hemodynamic parameters including right ventricular dilation, McConnell's sign, reduced tricuspid annular plane systolic excursion (TAPSE), interventricular septal flattening, abnormal right ventricular hemodynamics and in rare cases thrombi in the inferior vena cava, right atrium or ventricle en route to pulmonary arteries may also be visualized. This additional information is useful for selection of appropriate treatment modality. Thus, our objective is to provide a practical echocardiographic approach for risk stratification of patients with acute pulmonary embolism.
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8
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Patel AK, Kafi A, Bonet A, Shapiro SM, Oh SS, Zeidler MR, Betancourt J. Resolution of a Mobile Right Atrial Thrombus Complicating Acute Pulmonary Embolism With Low-Dose Tissue Plasminogen Activator in a Patient With Recent Craniotomy. J Intensive Care Med 2016; 31:618-21. [PMID: 27139009 DOI: 10.1177/0885066616646539] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 04/06/2016] [Indexed: 11/17/2022]
Abstract
Right heart thrombus in transit (RHTT) is a rare, severe form of venous thromboembolism that carries a high mortality rate. The optimal treatment for RHTT has not been well established. Thrombolysis is a therapeutic modality for RHTT but carries the risk of bleeding complications including intracranial hemorrhage. Low-dose thrombolysis has been shown to be effective in treating submassive pulmonary emboli without an increased risk in bleeding complications, but it has not been studied in patients with RHTT. Here, we discuss the case of a 74-year-old male with lung cancer and recent craniotomy with metastasectomy 30 days prior to admission presenting with RHTT and bilateral pulmonary emboli (PE). He was treated successfully with low-dose thrombolysis, despite his relative contraindication to thrombolytics. To our knowledge, this is the first reported case of low-dose alteplase (tissue plasminogen activator [tPA]) used to treat an in-transit PE in the setting of recent craniotomy with metastasectomy.
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Affiliation(s)
- Amisha K Patel
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Aarya Kafi
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Antonio Bonet
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shelly M Shapiro
- Pulmonary and Critical Care Section, Department of Medicine, West Los Angeles Veterans Affairs Healthcare Center and the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Scott S Oh
- Pulmonary and Critical Care Section, Department of Medicine, West Los Angeles Veterans Affairs Healthcare Center and the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Michelle R Zeidler
- Pulmonary and Critical Care Section, Department of Medicine, West Los Angeles Veterans Affairs Healthcare Center and the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jaime Betancourt
- Pulmonary and Critical Care Section, Department of Medicine, West Los Angeles Veterans Affairs Healthcare Center and the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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9
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Jammal M, Milano P, Cardenas R, Mailhot T, Mandavia D, Perera P. The diagnosis of right heart thrombus by focused cardiac ultrasound in a critically ill patient in compensated shock. Crit Ultrasound J 2015; 7:6. [PMID: 25995832 PMCID: PMC4437995 DOI: 10.1186/s13089-015-0023-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 04/19/2015] [Indexed: 02/06/2023] Open
Abstract
Right heart thrombus (RHT) is a life-threatening diagnosis that is rarely made in the emergency department (ED), but with the increasing use of focused cardiac ultrasound (FocUS), more of these cases may be identified in a timely fashion. We present a case of an ill-appearing patient who had an immediate change in management due to the visualization of RHT soon after arrival to the ED. The diagnosis was confirmed after a cardiology-performed ultrasound (US). This case illustrates the value of the recognition of RHT on FocUS and how US protocols designed for the evaluation of shock and shortness of breath may potentially be expanded to patients in a 'compensated' or 'pre-shock' state to expedite the correct diagnosis and to facilitate more timely management.
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Affiliation(s)
- Mansour Jammal
- />Division of Emergency Medicine, 300 Pasteur Drive, Alway Building, M121, Stanford, CA 94305 USA
| | - Peter Milano
- />Department of Emergency Medicine, Los Angeles County + USC Medical Center, 1200 N. State St # 1011, , Los Angeles, CA 90033 USA
| | - Renzo Cardenas
- />Department of Emergency Medicine, Los Angeles County + USC Medical Center, 1200 N. State St # 1011, , Los Angeles, CA 90033 USA
| | - Thomas Mailhot
- />Department of Emergency Medicine, Los Angeles County + USC Medical Center, 1200 N. State St # 1011, , Los Angeles, CA 90033 USA
| | - Diku Mandavia
- />Department of Emergency Medicine, Los Angeles County + USC Medical Center, 1200 N. State St # 1011, , Los Angeles, CA 90033 USA
| | - Phillips Perera
- />Division of Emergency Medicine, 300 Pasteur Drive, Alway Building, M121, Stanford, CA 94305 USA
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10
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Martires JS, Stein SJ, Kamangar N. Right heart thrombus in transit diagnosed by bedside ultrasound. J Emerg Med 2015; 48:e105-8. [PMID: 25605322 DOI: 10.1016/j.jemermed.2014.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 10/10/2014] [Accepted: 11/16/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Joanne S Martires
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, UCLA-Olive View Medical Center, UCLA Geffen School of Medicine, Sylmar, California
| | - Susan J Stein
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, UCLA-Olive View Medical Center, UCLA Geffen School of Medicine, Sylmar, California
| | - Nader Kamangar
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, UCLA-Olive View Medical Center, UCLA Geffen School of Medicine, Sylmar, California
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11
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Shankarappa RK, Math RS, Papaiah S, Channabasappa YM, Karur S, Nanjappa MC. Free floating right atrial thrombus with massive pulmonary embolism:near catastrophic course following thrombolytic therapy. Indian Heart J 2013; 65:460-3. [PMID: 23993011 DOI: 10.1016/j.ihj.2013.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 03/25/2013] [Accepted: 06/19/2013] [Indexed: 10/26/2022] Open
Abstract
A 28-year-old policeman presented with left lower limb deep vein thrombus, pulmonary embolism and a highly mobile right atrial clot. Thrombolytic therapy with IV Tenecteplase was administered. Within a few minutes after the Tenecteplase bolus, the patient's condition worsened dramatically with severe hypotension and hypoxemia. Immediate bedside transthoracic echocardiogram revealed that the mobile right atrium clot had disappeared completely presumably having migrated to the pulmonary circulation thus worsening the clinical condition. With intensive supportive measures the patient's condition was stabilized and he made a complete recovery. Prior to discharge, the echocardiogram revealed normal right ventricular function and a CT pulmonary angiogram performed after 2 months revealed near complete resolution of pulmonary thrombi. Thrombolytic therapy for right heart thrombus with pulmonary embolism can be a reasonable first line therapy but may be associated with hemodynamic worsening due to clot migration.
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12
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van de Gevel DFD, Hamad MAS, Schönberger J, van Dantzig JM, van Straten AHM. Right atrial thrombus migrating to the superior vena cava during surgery. Asian Cardiovasc Thorac Ann 2011; 19:363-6. [PMID: 22100935 DOI: 10.1177/0218492311421452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Free-floating right heart thrombi are extremely mobile structures that carry a very high mortality rate. We describe a case of pulmonary embolism with a free-floating right heart thrombus that migrated to the superior vena cava during the institution of cardiopulmonary bypass.
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13
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Mobile Right Atrial Thrombi in a Patient with the Hemoglobin SC Disease. Case Rep Med 2011; 2011:897167. [PMID: 21912556 PMCID: PMC3168297 DOI: 10.1155/2011/897167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Accepted: 07/07/2011] [Indexed: 11/17/2022] Open
Abstract
The formation of Intracardiac thrombi is rare in the absence of structural heart disease or atrial fibrillation. We describe a case of spontaneous right atrial thrombus formation that occurred in a patient with a hypercoagulable condition who had been sub optimally anticoagulated.
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Abstract
Echocardiography can be used for rapid and accurate risk stratification of patients with pulmonary embolism to appropriately direct the therapeutic strategies for those at high risk. Echocardiography is an ideal risk stratification tool in this regard because of its easy portability to the emergency room or to the bed side. It can be performed at a relatively low cost and at no risk to the patient. Furthermore, echocardiography allows repetitive noninvasive assessment of the cardiovascular and hemodynamic status of the patient and the response to the therapeutic interventions. Right ventricular hypokinesis, persistent pulmonary hypertension, a patent foramen ovale, and a free floating right heart thrombus are echocardiographic markers that identify patients at a higher risk for morbidity and mortality. Such patients warrant special consideration for thrombolysis or embolectomy.
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15
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Kirin M, Cerić R, Spoljarić M, Pehar M, Cavrić G, Spoljarić IR, Kirin I. The right atrial thrombus: the sword of Damocles with real risk of massive pulmonary embolism. Angiology 2008; 59:415-20. [PMID: 18388032 DOI: 10.1177/0003319707306218] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cases of 6 patients admitted at the intensive care unit for massive pulmonary embolism are reported. All patients presented with dyspnea, tachypnea, and tachycardia, and 4 were hypotensive and had syncope. Lung ventilation/ perfusion scans revealed perfusion defects in 4 patients. Transthoracic echocardiography (TTE) demonstrated acute cor pulmonale. It also revealed mobile right atrial thrombi in 5 patients, adherent thrombus in the right atrium in 1 patient and patent foramen ovale in 4 patients. Thrombolytic therapy was initiated in 4 patients, and 2 patients received heparin infusion only. Effects of thrombolysis were monitored using bedside TTE during the first 24 hours and in follow-up. The outcome of 4 patients who received thrombolytic therapy was good whereas other 2 patients, who received only heparin, died. Thrombotic mass disappeared 8 to 12 hours after initiation of therapy, and 10 weeks after discharge TTE showed normalized right ventricle dimensions and function in all 4 patients.
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Affiliation(s)
- Marijan Kirin
- Intensive Care Unit, Clinical Hospital Dubrava, Zagreb, Croatia.
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16
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Schliamser JE, Shiran A. Taenia cordis. J Am Soc Echocardiogr 2007; 20:1418.e9-11. [PMID: 17628414 DOI: 10.1016/j.echo.2007.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Indexed: 11/25/2022]
Abstract
Free-floating right heart thrombi are rare echocardiographic findings usually encountered in patients with massive pulmonary embolism and associated with poor prognosis. We report a case of a large free-floating right heart thrombus without clinically significant pulmonary embolism. The patient was treated conservatively with heparin and warfarin, and the thrombus resolved uneventfully.
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Affiliation(s)
- Jorge E Schliamser
- Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Zakynthinos E, Douka E, Daniil Z, Konstantinidis K, Markaki V, Zakynthinos S. Anuria due to acute bilateral renal vein occlusion after thrombolysis for pulmonary embolism. Int J Cardiol 2005; 101:163-6. [PMID: 15860405 DOI: 10.1016/j.ijcard.2004.01.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2003] [Accepted: 01/08/2004] [Indexed: 11/20/2022]
Abstract
Severe hemorrhage is the more frequent complication of thrombolysis, with intracranial bleeding the most critical one. We report a 73-year-old woman with major pulmonary embolism (PE), yet haemodynamically stable, in whom thrombolysis resulted in severe complications with acute renal failure (ARF) due to bilateral renal vein occlusion, quite unexpected; this complication has never been reported, as yet. We believe that disrupture of peripheral vein clots by thrombolysis led to migration of thrombi particles upwards to the inferior vena cava (IVC) and bilateral renal vein occlusion. However, the large thrombus straddled to the bifurcation of the main pulmonary trunk and extending to the right pulmonary artery, as visualized by transthoracic (TTE) and transesophageal echocardiogram (TEE), was not affected by thrombolysis. Finally, endogenous fibrinolytic activity, under low molecular weight heparin, resulted in a slow dissolution of the pulmonary thrombus and restoration of kidney function.
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18
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Ferrari E, Benhamou M, Berthier F, Baudouy M. Mobile thrombi of the right heart in pulmonary embolism: delayed disappearance after thrombolytic treatment. Chest 2005; 127:1051-3. [PMID: 15764793 DOI: 10.1378/chest.127.3.1051] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
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.
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Affiliation(s)
- Emile Ferrari
- Cardiology Department, Pasteur University Hospital, 30 Ave de la Voie Romaine, Nice 06002, France.
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19
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Pierre-Justin G, Pierard LA. Management of mobile right heart thrombi: a prospective series. Int J Cardiol 2005; 99:381-8. [PMID: 15771917 DOI: 10.1016/j.ijcard.2003.10.071] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2003] [Revised: 08/28/2003] [Accepted: 10/12/2003] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Gilbert Pierre-Justin
- University of Fort de France, Department of Cardiology, 97200 Fort De France, Martinique, France.
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20
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Abstract
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.
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Affiliation(s)
- Selim M Arcasoy
- Pulmonary, Allergy, and Critical Care Division, Columbia University College of Physicians and Surgeons, Lung Transplantation Program, New York Presbyterian Hospital of Columbia, Cornell University, New York, NY 10032, USA.
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Wirtz SP, Schmidt C, Hammel D, Hoffmeier A, Berendes E. Crossing atrial thrombus in a patient with recurrent pulmonary embolism. Crit Care Med 2002; 30:1902-5. [PMID: 12163814 DOI: 10.1097/00003246-200208000-00039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To report the detection of a thrombus entrapped in a patent foramen ovale by echocardiography in a patient with recurrent pulmonary embolism. DESIGN Case report. SETTING Intensive care unit of a university hospital. PATIENT A 62-yr-old man with initial deep venous thrombosis and recurrent minor pulmonary embolism followed by a severe embolic event with transitory hemiparesis 10 days after prostatectomy. INTERVENTION Systemic anticoagulation, surgical removal of a crossing atrial thrombus, closure of a patent foramen ovale, and venous thrombectomy. MEASUREMENTS AND MAIN RESULTS Transesophageal echocardiography revealed a large thrombus entrapped in a patent foramen ovale with portions in all four heart chambers. Intraoperatively, a 19-cm-long thrombus, shaped like the pelvic veins, was found. The patient was successfully weaned from cardiopulmonary bypass, requiring temporary positive inotropic support because of right ventricular dysfunction. Within 24 hrs of the operation, the patient was discharged to the intermediate care unit. CONCLUSIONS Recurrent pulmonary embolism can potentially result in paradoxic embolism in patients with a patent foramen ovale. In such patients, it may be crucial to monitor right ventricular function and exclude right-to-left shunts by transesophageal echocardiography, regardless of clinical symptoms. The patent foramen ovale should be closed. This case emphasizes an important indication for transesophageal echocardiography in critically ill patients.
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Affiliation(s)
- Stefan P Wirtz
- Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Münster, Münster, Germany.
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Abstract
BACKGROUND The presence of right heart thromboemboli complicating pulmonary thromboemboli carries with it an increased mortality rate compared to pulmonary thromboemboli alone, but little is known about the optimal management of this difficult clinical situation. This fact is highlighted in the case study of a patient with a 19-cm right atrial thrombus complicating bilateral pulmonary thromboemboli. STUDY OBJECTIVES We sought to determine the effects of anticoagulation therapy, thrombolysis, and surgical embolectomy on mortality rate in patients with right heart thromboemboli. DESIGN Retrospective analysis of all reported cases in the English language literature (1966 to 2000) of right heart thromboembolism in which age, sex, therapy, and outcome were reported. MEASUREMENTS AND RESULTS We analyzed 177 cases of right heart thromboembolism. Pulmonary thromboembolism was present in 98% of the cases. The patients were evenly divided by gender with an average age of 59.8 years (SD, 16.6 years) years. Dyspnea (54.2%), chest pain (22.6%), and syncope (17.5%) were the most common presenting symptoms. The treatments administered were none (9%), anticoagulation therapy (35.0%), surgical procedure (35.6%), or thrombolytic therapy (19.8%). The overall mortality rate was 27.1%. The mortality rate associated with no therapy, anticoagulation therapy, surgical embolectomy, and thrombolysis was 100.0%, 28.6%, 23.8%, and 11.3%, respectively. Using multivariate modeling with survival as the primary outcome, age and gender were not associated with mortality rate, but thrombolytic therapy was associated with an improved survival rate (p < 0.05) when compared either to anticoagulation therapy or surgery. CONCLUSION The presence of right heart thromboemboli may have diagnostic and therapeutic implications in pulmonary thromboembolism patients. A well-designed prospective, randomized trial is needed to determine the optimal treatment of right heart thromboemboli.
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Affiliation(s)
- Peter S Rose
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, MD 21224, USA
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Karavidas A, Matsakas E, Lazaros G, Panou F, Foukarakis M, Zacharoulis A. Emergency bedside echocardiography as a tool for early detection and clinical decision making in cases of suspected pulmonary embolism--a case report. Angiology 2000; 51:1021-5. [PMID: 11132994 DOI: 10.1177/000331970005101207] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Massive pulmonary embolism (PE) constitutes the most unexpected cause of death in necropsy. Consequently, prompt diagnosis and treatment is considered imperative. This article reports the case of a 37-year-old man who presented with cardiogenic shock due to PE as detected with bedside echocardiography in the emergency department. The authors wish to emphasize the usefulness of emergency bedside echo-Doppler for a prompt diagnosis and treatment of this life threatening condition.
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Affiliation(s)
- A Karavidas
- Department of Cardiology, Athens General Hospital G Gennimatas, Greece
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Jeon HK, Youn HJ, Yoo KD, Park JW, Kim HY, Rhim HY, Chae JS, Kim JH, Choi KB, Hong SJ. Transthoracic echocardiographic demonstration of massive pulmonary thrombus caused by protein C deficiency. J Am Soc Echocardiogr 2000; 13:682-4. [PMID: 10887354 DOI: 10.1067/mje.2000.104648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Few cases of pulmonary embolism detected by transthoracic echocardiography (TTE) have been reported. We present a case of a patient affected by pulmonary embolism caused by protein C deficiency. Transthoracic echocardiography showed a thrombus in transit (ie, visualization of a thrombus within the pulmonary artery). A hypercoagulable state caused by deficiency of protein C is a rare cause of pulmonary thromboembolism. Our experience demonstrates a massive pulmonary thrombus resulting from such a deficiency. Transthoracic echocardiography should be considered as the first diagnostic method for patients with suspected pulmonary embolism.
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Affiliation(s)
- H K Jeon
- Division of Cardiology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Greco F, Guzzo D. Treatment of Right Heart Thromboemboli With IV Recombinant Tissue-Type Plasminogen Activator. Chest 2000. [DOI: 10.1016/s0012-3692(15)32768-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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26
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Procopiou M, Perrier A. Treatment of right heart thromboemboli with IV recombinant tissue-type plasminogen activator. Chest 2000; 117:920-1. [PMID: 10713034 DOI: 10.1378/chest.117.3.920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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