1
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Alerhand S, Adrian RJ. What echocardiographic findings differentiate acute pulmonary embolism and chronic pulmonary hypertension? Am J Emerg Med 2023; 72:72-84. [PMID: 37499553 DOI: 10.1016/j.ajem.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/29/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) and pulmonary hypertension (PH) are potentially fatal disease states. Early diagnosis and goal-directed management improve outcomes and survival. Both conditions share several echocardiographic findings of right ventricular dysfunction. This can inadvertently lead to incorrect diagnosis, inappropriate and potentially harmful management, and delay in time-sensitive therapies. Fortunately, bedside echocardiography imparts a few critical distinctions. OBJECTIVE This narrative review describes eight physiologically interdependent echocardiographic parameters that help distinguish acute PE and chronic PH. The manuscript details each finding along with associated pathophysiology and summarization of the literature evaluating diagnostic utility. This guide then provides pearls and pitfalls with high-quality media for the bedside evaluation. DISCUSSION The echocardiographic parameters suggesting acute or chronic right ventricular dysfunction (best used in combination) are: 1. Right heart thrombus (acute PE) 2. Right ventricular free wall thickness (acute ≤ 5 mm, chronic > 5 mm) 3. Tricuspid regurgitation pressure gradient (acute ≤ 46 mmHg, chronic > 46 mmHg, corresponding to tricuspid regurgitation maximal velocity ≤ 3.4 m/sec and > 3.4 m/sec, respectively) 4. Pulmonary artery acceleration time (acute ≤ 60-80 msec, chronic < 105 msec) 5. 60/60 sign (acute) 6. Pulmonary artery early-systolic notching (proximally-located, higher-risk PE) 7. McConnell's sign (acute) 8. Right atrial enlargement (equal to left atrial size suggests acute, greater than left atrial size suggests chronic). CONCLUSIONS Emergency physicians must appreciate the echocardiographic findings and associated pathophysiology that help distinguish acute and chronic right ventricular dysfunction. In the proper clinical context, these findings can point towards PE or PH, thereby leading to earlier goal-directed management.
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Affiliation(s)
- Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, 150 Bergen Street, Newark, NJ 07103, USA.
| | - Robert James Adrian
- Department of Emergency Medicine, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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2
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Kim KW, Wheeler M, Schneider F, Carino G. Mechanical Thrombectomy for a Clot in Transit With Adherence to the Tricuspid Valve. Cureus 2023; 15:e46636. [PMID: 37936985 PMCID: PMC10627110 DOI: 10.7759/cureus.46636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2023] [Indexed: 11/09/2023] Open
Abstract
This case report investigates the management of a clot in transit (CIT), a rare but possibly life-threatening condition discovered in a small percentage of pulmonary embolism (PE) cases. CITs are thrombi lodged within the right-side heart chambers or the major veins, and there are currently no universal guidelines for their management though the literature has shown reduced mortality with reperfusion therapy compared to anticoagulation alone. In this case, a 96-year-old male who presented with a submassive PE was initially stabilized with anticoagulation and was then discovered to have a CIT with adherence to the tricuspid valve. The patient underwent a successful mechanical thrombectomy using the Inari FlowTriever (Inari Medical, Irvine, CA), an FDA-approved device for CIT removal. Overall, this manuscript supports this percutaneous intervention in intermediate to high-risk PE patients with concomitant CIT, offering an alternative to thrombolysis and cardiothoracic surgery, which carry their own risks. Furthermore, the unique characteristic of the CIT in this patient suggests a potential for further investigation into the diversity of CIT morphology and its significance.
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Affiliation(s)
- Kang Woo Kim
- Internal Medicine, Brown University, Providence, USA
| | - Mareril Wheeler
- Pulmonary and Critical Care, Brown University, Providence, USA
| | | | - Gerardo Carino
- Pulmonary and Critical Care, Brown University, Providence, USA
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3
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Li W, Liu Z, Chen X, Qian Y, Quan R, Xiong C, Gu Q, He J. Right heart thrombus in acute pulmonary embolism: A single center experience in China. Pulm Circ 2023; 13:e12291. [PMID: 37744669 PMCID: PMC10511828 DOI: 10.1002/pul2.12291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/22/2023] [Accepted: 09/11/2023] [Indexed: 09/26/2023] Open
Abstract
Right heart thrombus (RHT) is a rare but life-threatening condition in acute pulmonary embolism (APE) without clear management guidelines. This study aimed to address the clinical characteristics and outcomes of RHT-APE in Chinese patients. In this study, 17 RHT-APE and 329 non-RHT-APE patients, who were diagnosed between September 2015 and August 2019, were retrospectively recruited with the median follow-up was 360 days. The overall prevalence of RHT was 4.91% in APE. Its prevalence increased along the increase of APE risk stratifications. Comparisons showed that with higher proportion of male gender and younger age, RHT-APE patients also had worse hemodynamic instability and heart function, and higher risk stratification levels than non-RHT-APE patients. After adjusting by age and gender, multivariate logistic regression analysis found high/intermediate-high risk stratification, decreased right ventricular (RV) motion, NT-proBNP >600 pg/mL, and RV dysfunction were risk factors for RHT. Kaplan-Meier analysis showed non-RHT had better prognosis than RHT patients (30-day survival: log-rank: p < 0.001; 90-day survival: log-rank: p = 0.002). The multivariate logistic regression analysis showed RHT was an independent risk factor for 30-day mortality in APE. The subgroup analysis showed RHT would result in worse outcomes in patients who already had higher APE early mortality risk. RHT would increase the risk of 30- and 90-day mortality in APE. More attention should be paid to young male APE patients with decreased RV motion, NT-proBNP >600 pg/mL, RV dysfunction, or high level of risk stratification, to exclude the coexistence of RHT.
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Affiliation(s)
- Wen Li
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Zhi‐Ying Liu
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Xiao‐Xi Chen
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Yu‐Ling Qian
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Rui‐Lin Quan
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Chang‐Ming Xiong
- State Key Laboratory of Cardiovascular Disease, Center of Pulmonary Vascular Disease, National Center for Cardiovascular Diseases, Fuwai HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Qing Gu
- State Key Laboratory of Cardiovascular Disease, Key Laboratory of Pulmonary Vascular Medicine, Emergency Center, National Center for Cardiovascular Diseases, Fuwai HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
| | - Jian‐Guo He
- State Key Laboratory of Cardiovascular Disease, Center of Pulmonary Vascular Disease, National Center for Cardiovascular Diseases, Fuwai HospitalChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingChina
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4
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Cantu-Martinez O, Martinez Manzano JM, Peterson E, Tito S, Prendergast A, Jarrett SA, Chiang B, Wattoo A, Benzaquen S, Lo KB, Amanullah A. Clinical characteristics and treatment of patients with central pulmonary embolism and right heart thrombus. Echocardiography 2023. [PMID: 37212381 DOI: 10.1111/echo.15592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 04/24/2023] [Accepted: 05/02/2023] [Indexed: 05/23/2023] Open
Abstract
INTRODUCTION Right heart thrombus (RHT), also known as clot in transit, is an uncommon finding in pulmonary embolism (PE) that is associated with increased inpatient mortality. To date, there is no consensus on the management of RHT. Therefore, we aim to describe the clinical features, treatments, and outcomes of patients with simultaneous RHT and PE. METHODS This is a retrospective, cross-sectional, and single-center study of hospitalized patients with central PE who had RHT visualized on transthoracic echocardiography (TTE) from January 2012 to May 2022. We use descriptive statistics to describe their clinical features, treatments, and outcomes, including mechanical ventilation, major bleeding, inpatient mortality, length of hospital stay, and recurrent PE on follow-up. RESULTS Of 433 patients with central PE who underwent TTE, nine patients (2%) had RHT. The median age was 63 years (range 29-87), most were African American (6/9), and females (5/9). All patients had evidence of RV dysfunction and received therapeutic anticoagulation. Eight patients received RHT-directed interventions, including systemic thrombolysis (2/9), catheter-directed suction embolectomy (4/9), and surgical embolectomy (2/9). Regarding outcomes, 4/9 patients were hemodynamically unstable, 8/9 were hypoxemic, and 2/9 were mechanically ventilated. The median length of hospital stay was six days (range 1-16). One patient died during hospital admission, and two patients had recurrent PE. CONCLUSION We described the different therapeutic approaches and outcomes of patients with RHT treated in our institution. Our study adds valuable information to the literature, as there is no consensus on the treatment of RHT. HIGHLIGHTS Right heart thrombus (RHT) was a rare finding in central pulmonary embolism. Most patients with RHT had evidence of RV dysfunction and pulmonary hypertension. Most patients received RHT-directed therapies in addition to therapeutic anticoagulation.
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Affiliation(s)
- Omar Cantu-Martinez
- Department of Medicine, Albert Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, Pennsylvania, USA
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jose Manuel Martinez Manzano
- Department of Medicine, Albert Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, Pennsylvania, USA
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Philadelphia, Pennsylvania, USA
| | - Eric Peterson
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Cardiology, Albert Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Sahana Tito
- Department of Medicine, Albert Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, Pennsylvania, USA
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Philadelphia, Pennsylvania, USA
| | - Alexander Prendergast
- Department of Medicine, Albert Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, Pennsylvania, USA
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Philadelphia, Pennsylvania, USA
| | - Simone A Jarrett
- Department of Medicine, Albert Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, Pennsylvania, USA
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brenda Chiang
- Department of Medicine, Albert Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, Pennsylvania, USA
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ammaar Wattoo
- Department of Medicine, Albert Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, Pennsylvania, USA
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sadia Benzaquen
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Pulmonary and Critical Care Medicine, Albert Einstein Medical Center Philadelphia, Philadelphia, USA
| | - Kevin Bryan Lo
- Department of Medicine, Albert Einstein Medical Center Philadelphia 5501 Old York Road, Philadelphia, Pennsylvania, USA
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Philadelphia, Pennsylvania, USA
| | - Aman Amanullah
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Cardiology, Albert Einstein Medical Center Philadelphia, Philadelphia, USA
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5
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Zieliński D, Zygier M, Dyk W, Wojdyga R, Wróbel K, Pirsztuk E, Szostakiewicz K, Szatkowski P, Darocha S, Kurzyna M, Ciurzyński M, Machowski M, Pruszczyk P, Torbicki A, Biederman A. Acute pulmonary embolism with coexisting right heart thrombi in transit-surgical treatment of 20 consecutive patients. Eur J Cardiothorac Surg 2023; 63:6994185. [PMID: 36661312 DOI: 10.1093/ejcts/ezad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/12/2023] [Accepted: 01/19/2023] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES The presence of right heart thrombi in transit in the setting of acute pulmonary embolism is associated with high mortality. The optimal management in such cases is inconclusive. We present the results of surgical treatment of 20 consecutive patients diagnosed with high or intermediate-high risk pulmonary embolism with coexisting right heart thrombi in transit. METHODS A retrospective analysis was performed of all consecutive patients undergoing surgical treatment in the Medicover Hospital between 2013 and 2021 for acute pulmonary embolism with coexisting thrombi in-transit in right heart cavities. The diagnosis was based on echocardiography, computed tomography pulmonary angiography, and laboratory tests. Eligibility criteria for surgical treatment were acute pulmonary embolism with right heart thrombi in transit, right ventricular overload on imaging studies, and significantly elevated levels of cardiac troponin and NTproBNP. All patients were operated on with extracorporeal circulation using deep hypothermia and total circulatory arrest. The primary end-point was hospital all-cause mortality; secondary end-points were perioperative complications and long-term mortality. RESULTS The analysis included 20 patients. There was no in-hospital death. Nearly one-third of patients required temporal hemofiltration for postoperative renal failure, but this did not involve the need for dialysis at discharge. No neurological complications occurred in any patient. The mean follow-up was 46 months (range 13-98). There was one death in the long-term follow-up, not related to pulmonary embolism. CONCLUSIONS Surgical treatment of patients with acute pulmonary embolism and coexisting right heart thrombi in transit can provide favourable results.
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Affiliation(s)
- Dariusz Zieliński
- Cardiac Surgery Department, Medicover Hospital, Warsaw, Poland.,Lazarski University, Faculty of Medicine, Warsaw, Poland
| | - Marcin Zygier
- Cardiac Surgery Department, Medicover Hospital, Warsaw, Poland.,Lazarski University, Faculty of Medicine, Warsaw, Poland
| | - Wojciech Dyk
- Cardiac Surgery Department, Medicover Hospital, Warsaw, Poland.,Lazarski University, Faculty of Medicine, Warsaw, Poland
| | - Ryszard Wojdyga
- Cardiac Surgery Department, Medicover Hospital, Warsaw, Poland.,Lazarski University, Faculty of Medicine, Warsaw, Poland
| | - Krzysztof Wróbel
- Cardiac Surgery Department, Medicover Hospital, Warsaw, Poland.,Lazarski University, Faculty of Medicine, Warsaw, Poland
| | - Ewelina Pirsztuk
- Department of Anaesthesiology and Intensive Care, Medicover Hospital, Warsaw, Poland
| | | | - Piotr Szatkowski
- Department of Anaesthesiology and Intensive Care, Medicover Hospital, Warsaw, Poland.,Department of Anaesthesiology, National Institute of Cardiology, Warsaw, Poland
| | - Szymon Darocha
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
| | - Michał Ciurzyński
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Michał Machowski
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, European Health Centre, Otwock, Poland
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6
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Mathevosian S, Ranade M. Right Heart Clot-in-Transit: Endovascular Therapies. Semin Intervent Radiol 2022; 39:515-522. [PMID: 36561934 PMCID: PMC9767789 DOI: 10.1055/s-0042-1757942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Right heart thrombus is a challenging high mortality disease typically seen in the setting of pulmonary embolism. Traditional treatments have included anticoagulation, thrombolysis, and surgical embolectomy. Advances in recognition and treatment of clot-in-transit have led to the development of endovascular therapies increasingly becoming the preferred method of treatment due to rapid debulking and lower morbidity. Novel endovascular devices are large bore aspiration thrombectomy systems which mitigate the use of concomitant thrombolytics. The article reviews the disease process, relevant literature, and current endovascular devices and strategies for the treatment of right heart thrombus and clot-in-transit.
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Affiliation(s)
- Sipan Mathevosian
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Mona Ranade
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California
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7
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Abstract
INTRODUCTION Right heart free-floating thrombus in the absence of structural heart disease or atrial fibrillation is rare. When it travels to the heart into the lung, called thrombus-in-transit, may cause cardiopulmonary collapse and sudden death. The clinical presentation varies from mild respiratory symptoms to sudden death; however, there are few clinical case reports of giant, free-floating thrombus in the right heart in an asymptomatic patient, and the optimal management options have not been established. PATIENT CONCERNS A 36-year-old Asian woman presented to the emergency department with complaints of worsening swelling of the left lower extremity over 12 hours. DIAGNOSIS Left leg deep vein thrombosis accompanied by an asymptomatic giant right atrial thrombus and pulmonary embolism with a rare autoimmune disease of Evans syndrome. INTERVENTIONS Emergent surgical thrombectomy under cardiopulmonary bypass for right atrial thrombus. OUTCOMES The postoperative course was uneventful, and she was discharged on the eighth postoperative day with normal heart function and mild tricuspid regurgitation. CONCLUSION An additional diagnostic workup in cases of deep vein thrombosis is necessary for the rapid diagnosis of right heart thrombus and pulmonary embolism without delay. This case report illustrates that early recognition of venous thromboembolism and emergent thrombectomy of right heart thrombus-in-transit is crucial to prevent mortality.
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Affiliation(s)
- Ya-Chen Yang
- Kaohsiung Chang Gung Memorial Hospital Education Department, Kaohsiung, Taiwan
| | - Yen-Yu Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
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8
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Ozturk C, Dumantepe M. Successful treatment of right heart thrombus and high-risk pulmonary embolism with acoustic pulse thrombolysis using EKOS endovascular system. J Card Surg 2021; 36:2961-2964. [PMID: 33938576 DOI: 10.1111/jocs.15593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 03/26/2021] [Indexed: 11/26/2022]
Abstract
Currently, the only widely accepted indication for interventional treatment in cases of pulmonary embolism is hemodynamic instability or cardiogenic shock. However, the presence of a right-heart thrombus along with a pulmonary embolism is a poor prognostic indicator, and catheter directed thrombolysis with use of thrombolytic agents should also be considered in this circumstance. Optimal management of right heart thrombus and high-risk pulmonary embolism is still uncertain. Herein, we present the case of an 81-year-old woman who presented at our hospital after progressive dyspnea and a syncopal event. The transthoracic echocardiography showed massive bilateral pulmonary, right ventricular and mobile atrial thrombus and also right-sided enlargement. The patient was successfully treated with acoustic pulse thrombolysis using the EKOS EkoSonic system and echocardiography revealed complete resolution of her right-heart thrombus and her high-risk pulmonary embolism 2 days later.
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Affiliation(s)
- Cuneyt Ozturk
- Department of Cardiovascular Surgery, Florence Nightingale Hospital, Istanbul, Turkey
| | - Mert Dumantepe
- Department of Cardiovascular Surgery, Uskudar University School of Medicine, Istanbul, Turkey
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9
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Bayona Molano MDP, Salsamendi J, Mani N. Emergent mechanical thrombectomy for right atrial clot and massive pulmonary embolism using flowtriever. Clin Case Rep 2021; 9:1241-1246. [PMID: 33768819 PMCID: PMC7981718 DOI: 10.1002/ccr3.3739] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 11/27/2020] [Accepted: 12/12/2020] [Indexed: 11/11/2022] Open
Abstract
This case demonstrated a feasible alternative to treat "clot in transit" associated with pulmonary embolism using FlowTriever Inari device. The pre-existing approved AngioVac device requires extracorporeal circulation support and more invasiveness. FlowTriever permits mechanical thrombectomy with versatile approach without additional extracorporeal perfusion setting. Additional studies are required to reach a definitive conclusion.
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Affiliation(s)
| | | | - Naganathan Mani
- Department of Interventional RadiologyMallinckrodt Institute of RadiologySt LouisMOUSA
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10
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Merlo E, Grutta G, Tiberio I, Martelli G. Right Heart Thrombus in an Adult COVID-19 Patient: A Case Report. ACTA ACUST UNITED AC 2020; 6:237-42. [PMID: 33200095 DOI: 10.2478/jccm-2020-0039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 10/21/2020] [Indexed: 12/25/2022]
Abstract
Introduction Right heart thrombus (RiHTh) can be considered a rare and severe condition associated with thromboembolic phenomena. A case is described of a COVID-19 patient presenting with an isolated thrombus in the right ventricle. Case presentation An 80-years-old Caucasian male was admitted in an intensive care unit (ICU) for COVID-19 related acute respiratory distress syndrome. The patient showed signs of hemodynamic instability, elevated cardiac troponin I and altered coagulation. On further assessment, a thrombotic mass near the apex of the right ventricle was detected. Moreover, the apex and the anteroseptal wall of the right ventricle appeared akinetic. Following the administration of a therapeutic dose of unfractionated heparin over a forty-eight hour period, re-evaluation of the right chambers showed that the thrombotic mass had resolved entirely. Conclusion COVID-19 patients could constitute a population at risk of RiHTh. Routine use of echocardiography and a multidisciplinary approach can improve the management of this condition.
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11
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Torres C, Doukky R. Massive obliterative right heart thrombus presenting with near-syncope. Echocardiography 2019; 36:1596-1597. [PMID: 31287567 DOI: 10.1111/echo.14435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 06/14/2019] [Accepted: 06/15/2019] [Indexed: 11/28/2022] Open
Abstract
Intracardiac thrombi are commonly encountered as a complication of a recent myocardial infarction, heart failure, atrial fibrillation, or intracardiac devices. The prevalence of atrial thrombi in the absence of these risk factors is not well-described, but seems to be low. We present a case of a 51-year-old man with a massive mobile thrombus in the right heart extending through the tricuspid valve, diagnosed on echocardiography after presenting with a presyncopal episode.
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Affiliation(s)
- Christian Torres
- Department of Internal Medicine, Cook County Health, Chicago, Illinois
| | - Rami Doukky
- Department of Internal Medicine, Cook County Health, Chicago, Illinois.,Division of Cardiology, Cook County Health, Chicago, Illinois.,Division of Cardiology, Rush University Medical Center, Chicago, Illinois
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12
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Charif F, Mansour MJ, Hamdan R, Najjar C, Nassar P, Issa M, Chammas E, Saab M. Free-Floating Right Heart Thrombus with Acute Massive Pulmonary Embolism: A Case Report and Review of the Literature. J Cardiovasc Echogr 2018; 28:146-149. [PMID: 29911017 PMCID: PMC5989551 DOI: 10.4103/jcecho.jcecho_64_17] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Free-floating right heart thrombus (RHT) is an extreme medical emergency in the context of acute massive pulmonary embolism (PE). Despite the advances in early diagnosis, the management is still very debatable due to lack of consensus. We reported the case of a 66-year-old male, with a history of moderate renal dysfunction and dilated cardiomyopathy, who presented to the emergency department for acute dyspnea. His angiographic magnetic resonance imaging revealed bilateral extensive PE. Transthoracic echocardiography showed RHT with moderate right ventricular dysfunction and pulmonary hypertension. Venous Doppler of the lower extremities noted the presence of a floating clot in the right common femoral vein. The patient was managed successfully by thrombolytic therapy with tenecteplase. To the best of our knowledge, this is the first case report of RHT and PE from Lebanon. Published cases from Middle Eastern countries are scarse.
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Affiliation(s)
- Fida Charif
- Lebanese University, Faculty of Medical Sciences, Hadath, Lebanon
- Division of Pulmonary Medicine, Beirut Cardiac Institute, Beirut, Lebanon
| | - Mohamad Jihad Mansour
- Lebanese University, Faculty of Medical Sciences, Hadath, Lebanon
- Division of Cardiovascular Medicine, Clemenceau Medical Center, Beirut, Lebanon
| | - Righab Hamdan
- Division of Cardiovascular Medicine, Beirut Cardiac Institute, Beirut, Lebanon
| | - Claudette Najjar
- Division of Cardiovascular Medicine, Beirut Cardiac Institute, Beirut, Lebanon
| | - Pierre Nassar
- Division of Cardiovascular Medicine, Beirut Cardiac Institute, Beirut, Lebanon
| | - Mohamad Issa
- Department of Anesthesiology, Beirut Cardiac Institute, Beirut, Lebanon
| | - Elie Chammas
- Lebanese University, Faculty of Medical Sciences, Hadath, Lebanon
- Division of Cardiovascular Medicine, Clemenceau Medical Center, Beirut, Lebanon
| | - Mohamad Saab
- Division of Cardiovascular and Thoracic Surgery, Beirut Cardiac Institute, Beirut, Lebanon
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13
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Overeinder I, Nijs J, Droogmans S. Pulmonary embolism with large oscillating thrombus: an alternative approach. Acta Cardiol 2017; 72:483-484. [PMID: 28705046 DOI: 10.1080/00015385.2017.1310952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Ingrid Overeinder
- Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jan Nijs
- Department of Cardiac Surgery, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Steven Droogmans
- Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
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14
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Koulova A, Malekan R, Aronow WS, Cooper HA. Pulmonary embolism in transit. Ann Transl Med 2017; 5:209. [PMID: 28603724 DOI: 10.21037/atm.2017.03.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A 65-year-old woman with recently diagnosed ovarian cancer presented with near syncope, tachypnea, and hypoxia. Transthoracic echocardiography revealed a dilated and hypokinetic right ventricle and a large, mobile mass in the right atrium prolapsing across the tricuspid valve. She was diagnosed with pulmonary embolism in transit and emergent embolectomy was recommended.
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Affiliation(s)
- Anna Koulova
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Ramin Malekan
- Division of Cardiothoracic Surgery, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Wilbert S Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Howard A Cooper
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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15
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Papadimitraki ED, Papadopoulos D, Zerva K, Bassoulis D, Chatzigheorgiou E, Barbetseas J. Right heart thrombus causing syncope in an elderly patient. Age Ageing 2015. [PMID: 26220987 DOI: 10.1093/ageing/afv092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Pulmonary embolism and thromboembolic disease carry a high mortality if not recognised and managed appropriately. Herein we illustrate the case of a dehydrated elderly female patient with recurrent syncope who proved to have high risk pulmonary embolism and a free floating right heart thrombus. The echocardiographic findings of right heart thrombus and possible thrombi 'in transit' within a low flow inferior vena cava, guided a life-saving treatment in this frail elderly patient.
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Affiliation(s)
| | | | - Kanella Zerva
- Department of Cardiology, Laiko General Hospital, Athens, Greece
| | | | | | - John Barbetseas
- Department of Cardiology, Laiko General Hospital, Athens, Greece
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16
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Satiroğlu O, Durakoğlugil ME, Uğurlu Y, Sahin I, Doğan S, Ergül E, Karadağ Z, Bostan M. Successful thrombolysis using recombinant tissue plasminogen activator in cases of severe pulmonary embolism with mobile thrombi in the right atrium. Interv Med Appl Sci 2014; 6:89-92. [PMID: 24936311 DOI: 10.1556/imas.6.2014.2.6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 12/30/2013] [Accepted: 02/17/2014] [Indexed: 11/19/2022] Open
Abstract
Hereby, we report two cases of acute pulmonary embolism with concomitant right-sided thrombus, which were successfully treated using recombinant tissue plasminogen activator (rtPA). These patients had life-threatening acute right ventricular failure, which dramatically improved within hours following thrombolysis. These cases emphasize the clinical utility of rtPA for the treatment of life-threatening pulmonary embolism.
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Affiliation(s)
- Omer Satiroğlu
- Department of Cardiology, Recep Tayyip Erdoğan University Medical School Rize Turkey
| | | | - Yavuz Uğurlu
- Department of Cardiology, Recep Tayyip Erdoğan University Medical School Rize Turkey
| | - Ismail Sahin
- Department of Cardiology, Recep Tayyip Erdoğan University Medical School Rize Turkey
| | - Sitki Doğan
- Department of Cardiology, Recep Tayyip Erdoğan University Medical School Rize Turkey
| | - Elif Ergül
- Department of Cardiology, Recep Tayyip Erdoğan University Medical School Rize Turkey
| | - Zakir Karadağ
- Department of Cardiology, Recep Tayyip Erdoğan University Medical School Rize Turkey
| | - Mehmet Bostan
- Department of Cardiology, Recep Tayyip Erdoğan University Medical School Rize Turkey
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17
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Panduranga P, Mukhaini M, Saleem M, Al-Delamie T, Zachariah S, Al-Taie S. Mobile right heart thrombus with pulmonary embolism in a patient with polycythemia rubra vera and splanchnic vein thrombosis. Heart Views 2010; 11:16-20. [PMID: 21042459 PMCID: PMC2964707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Splanchnic vein thrombosis in patients with polycythemia rubra vera is well-known. Development of mobile right heart thrombus in these patients has not been reported previously. We describe a young patient with Polycythemia rubra vera and splanchnic vein thrombosis with ischemic bowel who underwent small bowel resection. He developed a large mobile right atrial thrombus and bilateral pulmonary embolism. He also had upper gastrointestinal bleed. His management was complicated and challenging due to multiple risk factors and co-morbid conditions. Thrombolysis was contraindicated and he refused surgical intervention. He was treated with anticoagulation with complete resolution of right atrial thrombus.
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Affiliation(s)
- Prashanth Panduranga
- Department of Cardiology, Royal Hospital, Muscat, Oman,Correspondence to:Dr. Prashanth Pandarunga, Department of Cardiology, Royal Hospital, Post Box 1331, Muscat-111, Sutanate of Oman.
| | | | | | - Taha Al-Delamie
- Department of Cardiothoracic surgery, Royal Hospital, Muscat, Oman
| | - Sunny Zachariah
- Department of Cardiothoracic surgery, Royal Hospital, Muscat, Oman
| | - Saqar Al-Taie
- Department of Radiology, Royal Hospital, Muscat, Oman
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