Right Heart Thrombus Research Articles

Early surgical treatment in patients with pulmonary embolism and thrombus-in-transit.

Floating right heart thrombi (RHT) are in transit from the legs to the pulmonary arteries and thus are a severe form of venous thromboembolism (VTE), with a high early mortality rate without treatment. There is a lack of evidence-based recommendations for its management. The objective of this study is to describe our experience in the surgical management of thrombus-in-transit and pulmonary embolism (PE) in a tertiary hospital. We recruited four patients with thrombus-in-transit and PE treated with early surgical embolectomy and anticoagulation. Epidemiologic, laboratory, imaging and clinical data of the thromboembolic episode and the subsequent course were collected. The sample included 3 males and 1 female, with a mean age of 49.7. The most frequent initial symptoms were dyspnea, syncope, chest pain and signs of deep vein thrombosis (DVT). Transthoracic echocardiogram (TTE) found the thrombus-in-transit in all the cases. The inicial treatment was unfractionated heparin (UFH) and urgent right atriectomy and manual removal of the thrombi. Three patients needed perioperative infusion of vasopressor drugs. All patients had right heart dysfunction at the time of diagnosis. The mean scoring in the Pulmonary Embolism Severity Index (PESI) was 90. All patients survived after 30 days of follow-up. Early surgical embolectomy of thrombus-in-transit is an effective option of management in selected patients, although the current evidence to support this approach is not definitive.

Floating right ventricular thrombus with bilateral pulmonary embolism in the absence of deep vein thrombosis and structural heart disease—a case report

Occurrence of a thrombus in the right heart is usually attributed to clots migrating from the deep venous system of the lower limbs. The presence of right heart thrombus in the absence of structural cardiac abnormalities and cardiac rhythm disturbances is rare. Here, we present an unusual occurrence of free-floating right ventricular thrombus with bilateral pulmonary embolism in the absence of a documented deep vein thrombosis and structural heart disease.

Ocena przebiegu klinicznego u chorych z ostrą zatorowością płucną i skrzeplinami w jamach prawego serca. Doświadczenia jednego ośrodka

Introduction. Assessment of the clinical course of patients with acute pulmonary embolism (PE) and a right heart thrombus (RiHT). Material and methods . The analysis included 13 consecutive patients with echocardiographically detected RiHT and acute PE who were treated in our department. The endpoints were 30-day all-cause mortality and 30-day acute PE-related mortality. When a clear alternative cause of death was reported, a non-acute PE-related death was diagnosed and this contributed to 30-day all-cause mortality. All other fatalities were classified as related to acute PE. Results. High risk acute PE was diagnosed in 4 of 13 patients, and intermediate risk acute PE was diagnosed in the remaining 9 patients. Thrombolysis was the first-choice treatment in 4 (31%) patients, 6 (46%) patients were only anticoagulated, and the remaining 3 (23%) patients underwent surgical treatment. The main indication for embolectomy was RiHT entrapped in a patent foramen ovale (PFO). Two patients died during the first 30 days; they were hemodynamically unstable and deaths occurred within 48 hours since the diagnosis. No hemodynamically stable patients died within 30 days since the diagnosis. Conclusions . Thirty-day mortality in patients with RiHT depended mostly on the patient’s clinical condition and was not related to the presence or morphology of the thrombus. Patients with shock or hypotension may possibly benefit more from primary invasive treatment compared to drug therapy.

Morphology of Right Heart Thrombi in Pulmonary Embolism: A Case Series and Analysis

Introduction: The occurrence of right heart thrombus (RiHT) in pulmonary embolism (PE) carries poor prognosis. Type A Thrombi are serpiginous, highly mobile with high mortality. Type B Thrombi are less mobile and have better prognosis. Type C is intermediate in all characteristics. Methods: This is an observational study done in patients presenting with RiHT with PE to the emergency unit of our institute from March to August 2016. A total of seven patient's clinical and electrocardiographic data were collected with a history of deep vein thrombosis or hypercoagulability. Results: This case series of seven patients with right heart thrombi in pulmonary embolism showed a predominance of male patients, with right ventricle dysfunction and pulmonary hypertension in all cases. Conclusion: Early fibrinolysis in type A thrombus had a favourable outcome. Mortality was 29% in our series.

Prognostic Significance of Right Heart Thrombi in Patients With Acute Symptomatic Pulmonary Embolism: Systematic Review and Meta-analysis

For patients diagnosed with acute pulmonary embolism (PE), the prognostic significance of concomitant right heart thrombi (RHT) lacks clarity. We performed a meta-analysis of studies that enrolled patients with acute PE to assess the prognostic value of echocardiography-detectable RHT for the primary outcome of short-term all-cause mortality and the secondary outcome of short-term PE-related mortality. Unrestricted searches were conducted of PubMed and Embase from 1980 through January 31, 2016, and used the terms "right heart thrombi," "pulmonary embolism," and "prognos.*" A random effects model was used to pool study results; Begg rank correlation method was used to evaluate for publication bias; and I2 testing was used to assess for heterogeneity. Six of 79 potentially relevant studies met the inclusion criteria (15,220 patients). Overall, 99 of 593 patients with echocardiography-detectable RHT died (16.7%[95%CI, 13.8-19.9]) compared with 639 of 14,627 without RHT (4.4%[95%CI, 4.0-4.7]). RHT had a significant association with short-term all-cause mortality in all patients (OR, 3.0 [95%CI, 2.2 to 4.1]; I2= 20%) and with PE-related death (three cohorts, 12,955 patients; OR: 4.8 [95%CI, 2.0-11.3; I2= 76%). Results were consistent for the prospective (two cohorts, 514 patients; OR, 4.8 [95%CI, 1.7-13.6]; I2= 56%) and the retrospective (four cohorts, 14,706 patients; OR, 2.8 [95%CI, 2.1 to 3.8]; I2= 0%) studies. In patients diagnosed with acute PE, concomitant RHT were significantly associated with an increased risk of death within 30days of PE diagnosis. PROSPERO registry; No.: CRD42016033960; URL: https://www.crd.york.ac.uk/prospero/.

Right heart thrombi in pulmonary embolism.

There is a lack of comprehensive data on the prevalence, predictors and prognostic significance of right heart thrombi (RHT) in pulmonary embolism.In this study of patients with pulmonary embolism from the Registro Informatizado de la Enfermedad TromboEmbólica (RIETE) registry, we assessed the prevalence and predictors of RHT, and the association between the presence of RHT and the outcomes of all-cause mortality, pulmonary embolism-related mortality, recurrences, and major bleeding through 30 days after initiation of pulmonary embolism treatment.Of 12 441 patients with pulmonary embolism and baseline echocardiographic data, 2.6% had RHT. The following increased the risk of RHT: younger age, previous bleeding, congestive heart failure, cancer, syncope, systolic blood pressure <100 mmHg, and arterial oxyhaemoglobin saturation <90%. Patients with RHT were significantly more likely to die from any cause (adjusted OR 2.50 (95% CI 1.62-3.84); p<0.001) and from pulmonary embolism (adjusted OR 4.29 (95% CI 2.45-7.48); p<0.001) during follow-up. RHT was associated with an increased risk of recurrence during follow-up (1.8% versus 0.7%; p=0.04). Major bleeding was similar in patients with and without RHT.In patients presenting with pulmonary embolism, RHT is relatively infrequent. Patients with RHT had a worse outcome when compared with those without RHT.

Outcome of patients with right heart thrombi: the Right Heart Thrombi European Registry.

Our aim was the assessment of the prognostic significance of right heart thrombi (RiHT) and their characteristics in pulmonary embolism in relation to established prognostic factors.138 patients (69 females) aged (mean±sd) 62±19 years with RiHT were included into a multicenter registry. A control group of 276 patients without RiHT was created by propensity scoring from a cohort of 963 contemporary patients. The primary end-point was 30-day pulmonary embolism-related mortality; the secondary end-point included 30-day all-cause mortality. In RiHT patients, pulmonary embolism mortality was higher in 31 patients with systolic blood pressure <90 mmHg than in 107 normotensives (42% versus 12%, p=0.0002) and was higher in the 83 normotensives with right ventricular dysfunction (RVD) than in the 24 normotensives without RVD (16% versus 0%, p=0.038). In multivariable analysis the simplified Pulmonary Embolism Severity Index predicted mortality (hazard ratio 2.43, 95% CI 1.58-3.73; p<0.0001), while RiHT characteristics did not. Patients with RiHT had higher pulmonary embolism mortality than controls (19% versus 8%, p=0.003), especially normotensive patients with RVD (16% versus 7%, p=0.02).30-day mortality in patients with RiHT is related to haemodynamic consequences of pulmonary embolism and not to RiHT characteristics. However, patients with RiHT and pulmonary embolism resulting in RVD seem to have worse prognosis than propensity score-matched controls.

Free floating thrombus in right heart associated with pulmonary embolism: The effect of streptokinase

Floating right heart thrombus in -transit originate from the deep veins of lower limbs, travel to the pulmonary arteries and is uncommon in patients with pulmonary embolism. This condition is a medical emergency due to the high risk of mortality. However, the most appropriate treatment is yet to be determined and there is no clear consensus in the literature on therapeutic management. We have described two cases of deep vein thrombosis complicated with pulmonary embolism and right heart thrombus, which were treated with streptokinase and had diverse outcomes.

Sağ Kalpte Solucanvari Trombüsü Olan Pulmoner Embolili Bir Hastanın Düşük Doz Fibrinolitik ile Tedavisi

Sağ Kalpte Solucanvari Trombüsü Olan Pulmoner Embolili Bir Hastanın Düşük Doz Fibrinolitik ile Tedavisi

RIGHT HEART THROMBI EUROPEAN REGISTRY

Assessment the prognostic significance of right heart thrombi (RiHT) in patients with pulmonary embolism (PE) according to RiHT size, shape, mobility in relation to established prognostic factors for 30 days mortality: hemodynamic instability, right ventricular dysfunction (RVD), Shock Index (SI)

Mobile Intracardiac Mass after Inguinal Hernia Repair: An Unresolved Treatment Dilemma.

Right heart thrombi (RHT) are rare but well-described entity in literature. Their isolation has been considered as confirmatory for the diagnosis of venous thromboembolism (VTE). Even though their isolation aids the diagnosis, physicians are faced with a difficult management dilemma giving the paucity of data to support any treatment decision. We present a case of RHT in an 81-year-old man who presented to hospital with a large mobile right heart thrombus in transit seen on transthoracic echocardiogram (TTE). He was successfully treated with anticoagulation alone. This case highlights the importance of TTE in establishing the diagnosis and describes the interplay of factors influencing treatment decision.

Successful Endovascular Thrombus extraction from the Right Auricle of the Patient Presenting with the Massive Fixed Right Heart Thrombus

Представлен случай успешного хирургического лечения массивного фиксированного тромба правых отделов сердца с рецидивирующей тромбоэмболией мелких ветвей легочных артерий. Источником тромбоэмболии явились тромбированные глубокие вены нижних конечностей. Первым этапом выполнена установка кава-фильтра в нижнюю полую вену, вторым — эндоваскулярная тромбоэкстракция тромба из правых отделов сердца и тромболизис. Несмотря на исходно тяжелое соматическое состояние пациента (выраженная дыхательная недостаточность, сердечная недостаточность, нарушение функции почек), а также пожилой возраст, в результате лечения удалось достичь значительного улучшения состояния пациента — исчезновения одышки, стабилизации гемодинамики, нормализации функции почек. Больной выписан в удовлетворительном состоянии. Ключевые слова: тромбоэмболия легочной артерии, тромб правых отделов сердца, тромбоз глубоких вен нижних конечностей. This paper reports a case of the successful surgical treatment of the massive fixed thrombus in the right heart combined with recurrent thromboembolism of the minor pulmonary artery branches. The source of thromboembolism was thrombosed deep veins of the lower extremities. At the first stage of the surgical intervention, the cava filter was installed in the inferior vena cava, the second stage consisted of endovascular thrombus extraction from the right heart and thrombolysis. Despite the initially severe somatic conditions of the patient including pronounced respiratory and cardiac insufficiency, renal dysfunction, and advanced age, the treatment resulted in the significant improvement of the patient’s state apparent as the disappearance of apnoea, stabilization of hemodynamics, and normalization of the renal function. The patient was discharged from the clinic in satisfactory condition.

Right heart thrombi european registry - preliminary results

Background: Although right heart thrombi (RIHT) are generally regarded as indicators of unfavorable outcome in patients with acute pulmonary embolism (APE), the optimal management of patients with RIHT is still under discussion. Therefore, multicentre, multinational RIHT European Registry (RIHTER) has been organized in order to assess the prognostic value of such thrombi. Methods: We investigated whether the presence and characteristics of RIHT has additional prognostic value to established risk factors (right ventricular dysfunction (RVD), simplified PESI score, Shock Index and elevated troponin levels) for 30 days mortality in patients with APE. Results: Ninety one (42F) patients aged 65,8±19,5yr with RIHT detected at TTE were analyzed. Forty three pts underwent TTE due to suspected APE, in 40 TTE was performed after APE diagnosis, and in 8 pts RIHT was detected accidentally. In 14 pts hemodynamic instability (BPs 5cm – 26 or <5cm – 59). In 15 pts right heart devices were present. 28 patients in addition to TTE underwent TEE. In 5 cases RIHT was lodged in PFO. Thrombolysis or urgent surgery was used in 52pts, while 39 others were anticoagulated only. Seventeen patients died with first 30 days - mortality 18.7%. Mortality in HI group seemed to be higher than in RVD (+) and RVD (-) 36%; 17%; 0% respectively, p=0,16. Mortality in anticoagulated pts was 23.1%, while in more aggressively treated pts 15.3%, p=0,5. Moreover, thrombolysed pts were more hemodynamically compromised when compared to anticoagulated pts: BPs 111.4±26mmHg vs 97.7±45mmHg; p=0,25. In univariable analysis presence of McConnell sign, sPESI score, shock index, BPs<90mmHg, shock, but not RIHT parameters were found to be mortality predictors. In multivariable analysis only hemodynamic shock predicted 30 days mortality. (HR 4.6; 95% CI 1.9-11.3; p =0.001) Conclusion: It seems that mortality in patient with right heart mobile thrombi is predominately related to their hemodynamic instability but not to RIHT size and mobility.

Management of right heart thrombi associated with acute pulmonary embolism: a retrospective, single-center experience

The mortality of right heart thrombi (RHT) associated with pulmonary embolism (PE) is increased about three to four times. The most devastating scenario is fragmentation of RHT and occurrence of recurrent PE. The reports regarding the management of RHT complicated with PE are very scarce in the current literature. Therefore, we report a single-center experience in this paper. From January 2006 to December 2011, data of all patients diagnosed with acute PE were analyzed retrospectively. Of the 312 acute PE cases confirmed with computed tomography, total 35 patients who were diagnosed with concomitant RHT (prevalence of 11%) by echocardiography were recruited. After excluding of six patients with metastatic malignancy a total 29 patients were accepted eligible for the analysis. In addition, catheter -induced thrombus (type B) were not included to the study. The difference between categorical variables was analyzed with Chi-square test and continuous variables were analyzed with Mann-Whitney U test. A p value of <0.05 was considered statistically significant. Overall mortality was high (34%) in study population: among undergoing surgery-100%, therapy with thrombolytics -18%, and heparin -27%. Troponin levels were found significantly higher in died patients than that in survived patients (p=0.03). There was no significant difference regarding to clinical and echocardiographic characteristics of patients received heparin versus thrombolytic except for shock index (p=0.02). In addition, patients treated with heparin had increased duration of hospitalization compared to subjects treated with thrombolytic (median: 8 vs 3 days p<0.01). Despite of the low incidence of RHT, a mortal course is still an important problem during PE. The decision on treatment modality should be performed based on the hemodynamic parameters, laboratory findings, and bleeding risk of the patients.

Snake-Like Thrombus in the Right Heart Causing Massive Pulmonary Embolism and a Basic but Important Diagnostic Tool for Rapid Differential Diagnosis: Transthoracic Echocardiography

Sag kalpte, trasntorasik ekokardiyograf ile saptanmis, yilanvari bir trombus olan, bir masif pulmoner tromboemboli vakasini sunmaktayiz. Transtorasik ekokardiyografi hem ucuz ve invazif olmayan hem de siklikla hipotansif, siyanotik ve konfuze olduklari icin kompleks ve pahali tanisal araclar icin uygun olmayan bu hastalarin ayirici tanisinda basit ama onemli bir tanisal aractir. Pulmoner embolizm hayati tehdit eden bir durumdur. Vakarlin 2/3’unde yanlis tani konulmaktadir. Sensitif olan dispne, hipotansiyon, gogus agrisi ve senkop gibi bulgular dusuk spesifisiteleri dolayisiyla siklikla klinisyeni yanlis yonlendirmekte vce uygun tedavinin gecikmesine neden olmaktadir. Transtorasik ekokardiyografi, bu sekilde benzer bulgular ile gelebilen hastaliklarin da ayirici tanisi acisindan da kullanislidir. (JAEM 2013; 12: 98-100) Anahtar kelimeler: Pulmoner, tromboemboli, ekokardiyografi, trombus Abstract

Type A: right atrial thrombus associated with a sub-massive pulmonary embolism.

The increased use of echocardiography in patients with pulmonary thrombo-embolic disease has led to the recognition of sub-massive pulmonary embolism (SMPE) and concurrent right-heart thrombus (RHT). When these findings coincide, they are associated with a poor prognosis, identifying a high-risk group that often requires a rapid management. Since echocardiographers become the "first responders" in this clinical scenario, it is important to raise awareness and familiarize the readers regarding the importance played by the echocardiography laboratory in the prompt diagnosis and management of this entity. We describe two patients presenting with SMPE with an associated simultaneous RHT and discuss their management.

Intracardiac thrombi in pulmonary embolism of a priori non high risk: therapeutic dilemma

Pulmonary embolism (PE) of a priori non high risk according to ESC guidelines, but coexisting with intracardiac thrombi is potentially a life threatening disease. The recommendations regarding therapy in such situations are not clear. We report two cases of PE with coexisting intracardiac thrombi. The 74 year-old woman was admitted after previous cardiac arrest in the course of PE with the presence of intracardiac thrombi in right ventricle. Due to lack of clinical improvement during heparin administration she was treated with thrombolysis. The 72 year-old obese woman with hypertension, diabetes and previous stroke with right-sided paresis was admitted after 2 episodes of loss of consciousness, with intracardiac thrombus in both right and left heart. Due to contraindications to both surgery and thrombolysis, she was treated with heparin. Both women recovered successfully. These cases illustrate the importance of individual treatment strategy.

Intra‐arrest formation of right‐heart thrombi – a case illustrated by real‐time ultrasonography

The presence of free-floating right-heart thrombus has been reported in a cardiac arrest patient in the periarrest period. Free-floating right atrial thrombus is a rare phenomenon seen in patients developing severe pulmonary embolism, and is associated with increased mortality. However, there have been no previously reported cases of right-heart thrombus formation during a resuscitated cardiac arrest. We present the pre-hospital case of a woman in the clinical setting of cardiogenic shock due to acute myocardial infarction who developed asystolic cardiac arrest on the scene. Recent implementation of ultrasonography into the regional pre-hospital care protocol enabled sonographic investigation before and during cardiac arrest. This allowed detection of right atrial septal thrombus formation in the course of advanced life support and its migration through the tricuspid valve. The pathophysiological consequences, clinical significance and potential therapeutic options are discussed.

Right heart thrombus entrapped in patent foramen ovale with pulmonary embolism in a patient with primary hypercoagulable state

Tromboembolik hastalik erken tani konulmadiginda hayati tehdit eden ciddi bir patolojidir. Pulmoner arterde masif okluzyon olusturdugunda, kalp yetmezligi de gelismisse genc insanlarda bile olume neden olabilir. Sag veya sol atriyumda trombus olmasi ise bu hastaligin morbidite ve mortalitesinde artisa sebep olur. Bu yazida patent foramen ovalenin tuzakladigi trombusu olan, masif pulmoner tromboemboli ve sag kalp yetmezligi gelisen 32 yasinda bir erkek olgu sunulmustur. Transtorasik ekokardiyografide interatriyal septuma yapisik sag atriyal trombusu olan hastaya masif pulmoner tromboemboli tanisi konulduktan sonra doku plazminojen aktivatoru (2 saatte 100 mg) infuzyonu uygulandi. Tedaviden 2 gun sonra yapilan ekokardiyografide sag atriyumdaki trombusun tamamen kayboldugu ve sag ventrikul boyutlarinda kuculme oldugu goruldu. Yapilan genetik incelemede, faktor V Leiden ve trombofili gen mutasyonu saptandi. Hastanin serum homosistein seviyeleri yuksek bulundu.

The first three-dimensional visualization of a thrombus in transit trapped between the leads of a permanent dual-chamber pacemaker: a case report

IntroductionTwo-dimensional echocardiography is a useful tool in diagnosing cardiac masses. However, the three-dimensional offline reconstruction technique of transesophageal echocardiography might be superior to two-dimensional transesophageal echocardiography in providing additional information of structural details.Case presentationWe report the case of a 76-year-old Caucasian man with a permanent dual-chamber pacemaker and a worm-like right-heart thrombus in transit. Two-dimensional transthoracic echocardiography and two-dimensional transesophageal echocardiography showed that it was debatable as to whether "the worm" was originating from the leads. Offline three-dimensional transesophageal echocardiography reconstruction technique proved superior in identifying the cardiac mass as a thrombus trapped between the leads of the pacemaker. The thrombus was successfully dissolved by systemic heparin therapy.ConclusionsThe three-dimensional transesophageal echocardiography is useful and effective in patients with implanted pacemakers or defibrillators when other closely competing imaging modalities are contraindicated, such as magnetic resonance imaging. In patients with pacemakers and trapped thrombus in transit for whom surgical therapy might be a high risk, medical therapy seems to offer a safer and convincing alternative. Whether the management of right-heart thrombi has to be modified due to the presence of pacemaker leads is controversial.