Abstract
Acute pulmonary embolism (PE) is a common disease which frequently results in life-threatening right ventricular (RV) failure. High-risk PE, presenting with hypotension, shock, RV dysfunction or right heart thrombus is associated with a high mortality, particularly during the first few hours. Accordingly, it is important to commence effective therapy as soon as possible. In the case described in this report, a 49-year-old woman with myotonic dystrophy type 1 presented with acute respiratory failure and hypotension. Transthoracic echocardiography showed signs of right heart failure and a mobile right heart mass highly suspicious of a thrombus. Based on echocardiographic findings, acute thrombolysis was performed resulting in hemodynamic stabilization of the patient and complete resolution of the right heart thrombus. This case underscores the important role of transthoracic echocardiography for the diagnosis, management and monitoring of PE and underlines the efficacy and safety of thrombolysis in the treatment of PE associated with right heart thrombus.
Highlights
Right sided heart thrombi can be found in 4-18% of patients presenting with acute pulmonary embolism [1,2]
They may develop within the right heart chambers or origin from peripheral venous clots that got stuck in right heart structures on their way to the lungs
Myotonic Dystrophy Type 1 is an autosomal dominant multisystem disorder caused by a mutated expansion of a CTG repeat in the 3' untranslated region of a serine-threonine kinase gene on chromosome 19 [7]
Summary
Right sided heart thrombi can be found in 4-18% of patients presenting with acute pulmonary embolism [1,2]. Type A thrombi have a worm like shape, are extremely mobile and mostly represent peripheral venous clots which temporarily lodge into the right heart Due to their extreme mobility these clots are at high risk for severe and often fatal pulmonary embolism. Echocardiography on day two after thrombolytic therapy showed a complete resolution of the right sided heart thrombus (Figure 3) See Additional file 4. CT scan of the chest two days after thrombolytic therapy showed no severe pulmonary embolism indicating that thrombolytic therapy was successful and the disappearance of the right heart thrombus was rather due to in situ lysis than due to migration to the pulmonary arteries. Heparin-induced thrombocytopenia type II and activated protein C-resistance could be excluded
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