Article, Cardiology

A floating thrombus of the right ventricle in severe massive pulmonary embolism

Case Report

A floating thrombus of the right ventricle in severe massive pulmonary embolism

Abstract

Floating right heart thrombus (FRHT) is a severe presentation of Thromboembolic disease and usually coexists with massive pulmonary embolism. Patients with FRHT are more hemodynamically compromised and usually have a higher mortality rate than patients without FRHT. An echocardiographic finding of FRHT is important because it identifies as poor prognosis. The Optimal treatment in patients with FRHT remains uncertain. Heparin is more often an anticoagulant than a lytic agent. Several studies suggested that thrombolytic therapy has advantages in treating such patients. Early diagnosis and emergency therapy are important in treating patients with FRHT in the emergency department and they might have fatal outcomes when treated only with heparin.

Floating right heart thrombus (FRHT) is a severe presentation of thromboembolic disease and usually coexists with massive pulmonary embolism. Patients with FRHT are more hemodynamically compromised and usually have a higher mortality rate than patients without FRHT [1,2]. An FRHT is “in transit” from the legs to the pulmonary arteries and can embolize at any moment [3,4]. It can be detectable by transthoracic echocardiography [5,6]. Patients with FRHT have a poor prognosis. The mortality rate is high (21%-44%) [2,7]. Early diagnosis and emergency treatment is important. Although guidelines for FRHT treatment have not been established, heparin alone might not be adequate.

An 85-year-old man presented at our emergency depart- ment (ED) with a history of hypertension, congestive heart failure, Paroxysmal atrial fibrillation, and intracranial stroke. He denied connective tissue disease, malignancy, recent trauma, or history of surgery. He presented with abrupt dyspnea and had had a near-syncopal episode at home. On arrival in our ED, the patient had an initial Glasgow Coma Scale of E4V4M5, a blood pressure of 166/72 mm Hg, a heart rate of 106 beats per minute, and a respiratory rate of 18 breaths per minute. There were no swollen extremities. While breathing 100% oxygen, arterial blood gas measurements showed pH 7.578, PaCO2 = 16.5 mm Hg, PO2 = 61.8 mm Hg,

HCO3 = 15.1 mmol/L, O2 sat = 95.2%. respiratory alkalosis with metabolic compensation was noted. The result of an initial electrocardiogram showed atrial fibrillation with a controlled ventricular rate without a Mcginn-White pattern (S1Q3T3). Transthoracic echocardiography showed a float- ing “worm-like” thrombus 10 cm in length protruding through the Tricuspid valve and moderated pulmonary hypertension (Fig. 1). A contrast-enhanced computed tomography scan at the level of the pulmonary trunk showed Filling defects of contrast in bilateral pulmonary arteries, and interlobar and segmental arteries with multichamber enlarge- ment (Fig. 2). We advised the patient to accept thrombolytic therapy. Unfortunately, he refused because of fear of side effects of thrombolytic medications. Thus, this patient was treated with heparin alone. Progressive shock and desatura- tion (SpO2 90% under 100% oxygen) occurred even after aggressive resuscitation and airway management were done. The patient died within 12 hours of arriving at our ED.

Floating right ventricular thrombi are uncommon but probably underdiagnosed. The prevalence of right ventri- cular thrombi was 4% to 18% in patients with pulmonary embolism in previous studies [1,2,7,8]. An echocardio- graphic finding of FRHT is important because it identifies as poor prognosis and high mortality rate. This patient had a

Fig. 1 A transthoracic echocardiogram demonstrating a mobile right atrial thrombus 10 cm in length protruding through the tricuspid valve (arrows).

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1071.e2 Case Report

Fig. 2 Contrast-enhanced computed tomographic scan at the level of pulmonary trunk demonstrates large thrombi in bilateral pulmonary arteries (arrows).

history of congestive heart failure and arteriosclerosis. Thus, stasis of thrombi in the dilated right ventricle due either to acute pulmonary embolism or to preexisting congestive heart failure, or both, seemed to enhance the risk of FRHT, regardless of whether it was because of in situ thrombosis or to entrapment of transiting thrombi. The optimal treatment in patients with FRHT remains uncertain. However, several studies suggested that thrombolytic therapy has advantages in treating such patients [5,7,9]. Chartier et al [7] reported that mortality rates for different treatments: surgery (47.1%), thrombolytic agents (22.2%), heparin alone (62.5%), and interventional percutaneous techniques (50.0%). Pierre- Justin et al [5] reported increased systolic blood pressure, PaO2, PaCO2, and decreased heart and respiratory rates after infusion of thrombolytic agents. Furthermore, Ferrari et al [9] reported marked improvement in right ventricular hemody- namic status after thrombolytic therapy. Decreased right ventricle/left ventricle diastolic diameter ratio and decreased systolic pulmonary pressure was noted after thrombolytic therapy. Also, right ventricular thrombi disappeared in follow-up echocardiography. Heparin is more often an anticoagulant than a lytic agent. Therefore, heparin alone might be insufficient in treating patients with FRHT [2].

Early diagnosis and emergency therapy is important in treating patients with FRHT in the ED. We want to remind ED physicians that patients with FRHT might have fatal outcomes when treated only with heparin.

Shiau-Ling Huang MD Chiao-Hsuan Chien MD Yu-Che Chang MD

Department of Emergency Medicine Chang Gung Memorial Hospital

Chang Gung University College of Medicine Gueishan Shiang, Taoyuan, Taiwan 333, R.O.C.

E-mail address: [email protected] doi:10.1016/j.ajem.2008.03.045

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