Abstract
BackgroundFloating right heart thrombi (RHT) represent an underdiagnosed, potentially hazardous, and to some extent rare phenomenon in patients presenting with acute pulmonary embolism (APE). Emergent treatment is usually required for such a condition.Case presentationA 19-year-old young lady presented with progressive shortness of breath, marked renal impairment, thrombocytopenia, and a highly oscillating huge right atrial mass. After she was admitted to the intensive care unit, she arrested in asystole and was resuscitated, and her electrocardiogram (ECG) showed evidence of acute anterior myocardial infarction. Urgent cardiac surgery to remove the right atrial mass was proposed by the heart team as the best option of management. Surgery was emergently performed with extra-corporeal membrane oxygenator (ECMO) as a support. Following surgery, mechanical support and vasopressors were successfully weaned and the patient achieved a good recovery.ConclusionsA pulmonary embolism response team (PERT) approach should always be considered where a multidisciplinary team involving a cardiologist, radiologist, cardio-thoracic surgeon, radiologist, and intensivist shall determine the management strategy for a challenging presentation of a massive pulmonary embolism or floating right heart thrombi causing the hemodynamically unstable clinical condition.
Highlights
Floating right heart thrombi (RHT) represent an underdiagnosed, potentially hazardous, and to some extent rare phenomenon in patients presenting with acute pulmonary embolism (APE)
2 years before presenting to us, she had a purpuric eruption and was found to have severe thrombocytopenia. Her platelets reached 10,000, and after exclusion of all other possible causes, she was diagnosed with immune thrombocytopenic purpura (ITP) and was kept on steroids
Right heart thrombi (RHT) result either from migrating blood clots from deep venous thrombosis, or they may form in situ predominately due to atrial fibrillation
Summary
Right heart thrombi represent a quite challenging diagnosis that requires a precise determination of its source, morphology, anatomical extent, and clinical presentation. Nephrotic syndrome that presents with a very low serum albumin represents a prothrombotic condition with a high incidence of venous thromboembolism. Surgical embolectomy remains one of the golden modes of its management. A multidisciplinary team is the cornerstone for successful diagnosis, treatment, and follow-up of this risky clinical condition. Mechanical support of both ventricles may be needed in such critically ill patients and is highly deemed for speed recovery in the early post-operative period
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