Successful right atrial thrombus lysis with alteplase in a nine month old infant

Kristina Lah Tomulić ,Neven Frleta ,Neven Čače ,Jelena Roganović ,Srđan Banac ,Vjekoslav Tomulić ,David Gobić

doi:10.22514/sv81.052013.11

Abstract

Objective. To present the case of an infant with a catheter related atrial thrombus resolved with local instillation of alteplase. Clinical presentation. Echocardiography (ECHO) was performed in an infant with sepsis to estimate cardiac contractility, and a large mobile thrombus (28 x 8 mm) was detected in the right atrium. A left subclavian, double lumen, central venous line (CVL, 4 French, 8 cm), inserted 10 weeks previously, was left in place. Standard treatment with enoxaparine was commenced twice daily for 10 days at a dose of 1 mg/kg. Repeat ECHO showed no changes in thrombus size or mobility. Therefore, alteplase was administered into the distal catheter (1 mg in normal saline) at a dose of 110% of its priming volume. The dwelling time was 2 hours. Since no changes in thrombus size were observed, the same dose was given into the proximal catheter. ECHO performed 24 hours later showed a significant reduction in thrombus size. The third dose of alteplase was administered into the proximal catheter. ECHO showed complete dissolution of the right atrial thrombus. No bleeding was observed during and following therapy, and there were no signs of hemodynamic instability. The CVL was safely removed the same day and no endoluminal thrombus was seen. Conclusion. Local instillation of alteplase in three doses was a safe and effective approach to the management of a large catheter-related intraatrial thrombus. Systemic thrombolytic therapy, associated with an increased risk of bleeding, and open heart surgery were avoided.

Highlights

The care and treatment of children with acute or chronic diseases has been facilitated by the use of central venous lines (CVL)
To present the case of an infant with a catheter related atrial thrombus resolved with local instillation of alteplase
Subsequent ECHO showed no changes in thrombus size, so a second dose of alteplase was administered into the proximal catheter

Summary

Introduction

The care and treatment of children with acute or chronic diseases has been facilitated by the use of central venous lines (CVL). [1] The KIDCAT (Kids with CatheterAssociated Thrombosis) study showed that the incidence of thrombosis in children with short-term central venous catheters was 28% and 20% of them had clinical symptoms or had developed CVL occlusion. ECHO performed after ten days of treatment with enoxaparine showed no signs of improvement. Subsequent ECHO showed no changes in thrombus size, so a second dose of alteplase was administered into the proximal catheter. After another two hours, ECHO showed significant reduction in thrombus size. The third dose of alteplase was administered into the proximal catheter 24 hours later. After a dwelling time of 2 hours, ECHO revealed complete resolution of the thrombus (figure 2). Therapy with enoxaparine continued at a prophylactic dose (0.5 mg/kg twice daily) for the three months

Findings

Discussion

Conclusion