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e A: CT pulmonary angiogram demonstrating thrombi in right and left pulmonary artery. B: CT Pulmonary angiogram demonstrating thrombus in the right atrium. C: CT Pulmonary angiogram two months after pulmonary embolism demonstrating marked reduction in clot burden. D: CT Pulmonary angiogram two months after pulmonary embolism demonstrating a normal sized right ventricle.
Source publication
A 28-year-old policeman presented with left lower limb deep vein thrombus, pulmonary embolism and a highly mobile right atrial clot. Thrombolytic therapy with IV Tenecteplase was administered. Within a few minutes after the Tenecteplase bolus, the patient's condition worsened dramatically with severe hypotension and hypoxemia. Immediate bedside tra...
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Citations
... 5 Thrombolysis has been described to have better outcomes than anticoagulation alone or surgery, 1 but a report of sudden nearcatastrophic embolization post-thrombolysis has been described. 14 Thrombolysis should be particularly cautioned in type B thrombus in fear of dissolving the stalk connecting the thrombus to the cardiac wall. 4 In contrast, Barrios et al. 15 showed no significant difference in mortality in patients receiving anticoagulation therapy alone vs. anticoagulation with reperfusion therapy. ...
Background
Right heart thrombus (RHTh) complicated by pulmonary embolism (PE) usually presents as a medical emergency with significant haemodynamic instability. However, less is known about subacute presentations.
Case summary
We present a 74-year-old haemodynamically stable gentleman with a 3-week history of mild pleuritic chest pain and exertional dyspnoea preceded by lower respiratory tract infection. Early trans-thoracic echocardiogram (TTE) revealed a 3 cm elongated tricuspid valve thrombus with right ventricular dysfunction, new-onset atrial fibrillation, and new-onset severe left ventricular impairment. Subsequent computed tomography pulmonary angiogram showed widespread bilateral pulmonary emboli with retrograde opacification of the hepatic veins. The RHTh successfully resolved with warfarin therapy with no further complications, and the patient was discharged on Day 8 of hospitalization.
Discussion
An early TTE is crucial in detecting the RHTh in patients suspected of PE and can significantly change the management compared with uncomplicated PE. The index of suspicion for PE and RHTh should remain high even in subacute cases.
... However, this has not been seen as a complication in prospective studies. 10,12 Intracranial hemorrhage is the most feared complication of thrombolytic therapy, and it has been reported in less than 1% of patients in clinical trials and in 3% of patients in a national registry. 13,14 The randomized and double-blinded Pulmonary Embolism Thrombolysis (PEITHO) trial reported a major bleeding rate of 11.5% and hemorrhagic stroke of 2.0% within 1 week of full-dose tenecteplase. ...
Right heart thrombus in transit (RHTT) is a rare, severe form of venous thromboembolism that carries a high mortality rate. The optimal treatment for RHTT has not been well established. Thrombolysis is a therapeutic modality for RHTT but carries the risk of bleeding complications including intracranial hemorrhage. Low-dose thrombolysis has been shown to be effective in treating submassive pulmonary emboli without an increased risk in bleeding complications, but it has not been studied in patients with RHTT. Here, we discuss the case of a 74-year-old male with lung cancer and recent craniotomy with metastasectomy 30 days prior to admission presenting with RHTT and bilateral pulmonary emboli (PE). He was treated successfully with low-dose thrombolysis, despite his relative contraindication to thrombolytics. To our knowledge, this is the first reported case of low-dose alteplase (tissue plasminogen activator [tPA]) used to treat an in-transit PE in the setting of recent craniotomy with metastasectomy.
... Previously published case reports describe successful management of mobile RHT via anticoagulation with heparin [65][66][67], systemic thrombolysis [68][69][70][71][72][73][74], catheterdirected thrombolysis [75], surgical embolectomy under cardiopulmonary bypass [76][77][78], and percutaneous embolectomy [79][80][81][82]. No consensus has been achieved, as there have been no prospective, randomized trials to date. ...
... In addition, thrombolysis in patients with PFO increases the risk of fragmentation and paradoxical embolus. There have also been case reports of patients who deteriorated after thrombolysis [72,86] with the suspected mechanism being increased clot burden traveling into the pulmonary vasculature after lysis of thrombus. On the other hand, opting for surgery is not without its risks -waiting time to set up the operating rooms, lack of surgical expertise, anesthesia, cardioplegia, and inability to remove or dissolve distal thrombi. ...
Right heart thrombus (RHT) is a life-threatening diagnosis that is rarely made in the emergency department (ED), but with the increasing use of focused cardiac ultrasound (FocUS), more of these cases may be identified in a timely fashion. We present a case of an ill-appearing patient who had an immediate change in management due to the visualization of RHT soon after arrival to the ED. The diagnosis was confirmed after a cardiology-performed ultrasound (US). This case illustrates the value of the recognition of RHT on FocUS and how US protocols designed for the evaluation of shock and shortness of breath may potentially be expanded to patients in a ‘compensated’ or ‘pre-shock’ state to expedite the correct diagnosis and to facilitate more timely management.
Electronic supplementary material
The online version of this article (doi:10.1186/s13089-015-0023-7) contains supplementary material, which is available to authorized users.
... Thrombolytic therapy has been advocated as the first treatment modality [1,3,5,[10][11][12][13] due to its widespread availability in clinical practice and its ability to hasten thrombus breakdown thereby lowering the overall thrombus burden and improve right and left ventricular hemodynamics [5,10]. Successful thrombolysis has been reported with both slow and rapid infusion of Tissue Plasminogen Activator (tPA) [14]. ...
... Thrombolytic therapy has been advocated as the first treatment modality [1,3,5,[10][11][12][13] due to its widespread availability in clinical practice and its ability to hasten thrombus breakdown thereby lowering the overall thrombus burden and improve right and left ventricular hemodynamics [5,10]. Successful thrombolysis has been reported with both slow and rapid infusion of Tissue Plasminogen Activator (tPA) [14]. ...
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.
... Giant thrombi (type B) (5), which develop within the heart chambers, are usually fixed, well-organized and fibrotic, intimately associated with the atrial wall and very unlikely to respond to thrombolytic therapy; in fact, in such cases, thrombolytic therapy is often ineffective and unsafe. The few cases of giant atrial thrombi reported in the literature suggest open surgical removal as the procedure of choice (8). ...
Permanent central venous catheters (CVC), such as Port-a-Cath®, Hickmann® or PICC®, are widely used in oncology patients for cancer treatment. Thrombosis is a frequent complication that should be ruled out, as it is associated with potentially severe infection and hemodynamic consequences. This is the case report of a male patient who was undergoing chemotherapy for colon cancer. The patient presented with an atrial mass secondary to a CVC-related organized thrombus located inside the atrial cavity. The mass was inducing a massive right-to-left intracardial shunt due to a persistent foramen ovale and signs of respiratory failure that required surgical intervention to remove the intracardial mass.
Polycythemia, characterized by an excess of red blood cells (RBCs), is a common occurrence in individuals with chronic obstructive pulmonary disease (COPD) due to chronic hypoxia resulting from impaired lung function. While polycythemia may have some protective effects for COPD patients on long-term oxygen therapy, it can also increase the risk of life-threatening complications such as pulmonary embolism (PE). This review explores the impact of polycythemia on COPD patients, delving into its epidemiology, risk factors, and potential consequences. The prevalence of polycythemia in COPD varies from 6% to 10.2% in outpatient settings and is associated with factors like smoking, male gender, impaired lung function, and severe hypoxemia. The elevated red blood cell count can thicken the blood, increasing the risk of blood clots and cardiovascular complications. Proper management of polycythemic COPD involves addressing increased blood viscosity, managing thromboembolic risks, and optimizing cardiovascular health. Therapeutic interventions include phlebotomy, low-dose aspirin, and oxygen therapy to reduce complications and improve outcomes. Additionally, new cytoreductive therapies may offer promising treatment options for primary polycythemia. However, further research is required to enhance our understanding and refine care for individuals with polycythemic COPD, with the ultimate goal of mitigating complications, improving quality of life, and enhancing long-term prognosis. Clinicians must remain vigilant in managing polycythemia in COPD to optimize patient outcomes and reduce the burden of associated complications.
Introduction. Right heart thrombus is uncommon and it is usually detected by echocardiography in patients with venous thromboembolism. Thrombi attached to the atrial or ventricular wall have a good prognosis; however, free-floating “snake-like” thrombi are usually associated with massive, unstable pulmonary embolism and high mortality. Case Report. A 43-year-old male patient visited a cardiologist complaining about rapid fatigue and shortness of breath with minimal effort in the last week. An echocardiographic examination confirmed a right heart thrombus and a pulmonary embolism. After the examination, the case was presented to the Heart Team, which made a decision to perform a surgery. After the usual preoperative preparation for emergency surgery, the patient underwent surgery under general endotracheal anesthesia via median sternotomy. Conclusion. The right heart thrombus is associated with risks of possible embolization to the pulmonary circulation and potential circulatory collapse. There was a considerable discrepancy between the apparently mild clinical presentation and the alarming echocardiographic finding of a huge free-floating thrombus. Despite the lack of standardized and precise recommendations for the optimal therapeutic strategy, surgical approach seems to be the best option in emergency cases with large free-floating thrombi.
Right heart thrombus is a slightly detectable condition. In patients presenting with acute pulmonary embolism, the finding of thrombus in transit has been associated with high in-hospital mortality. We present a case of a 50-year-old male patient with acute pulmonary embolism and a thrombus in transit in the right atrium. We took the decision to perform fibrinolysis with tenecteplase, presenting significant improvement in the clinical condition, without any complications related to the therapy. Our case demonstrates the effectiveness of thrombolytic therapy in cases of pulmonary embolism and thrombus in transit in right chambers.
As healthcare delivery in the USA transforms into a model that at its core requires value-based considerations, ischemic stroke is confronted by intersecting forces. Modern techniques allow rapid revascularization in the majority of patients with large vessel occlusions. Dramatic advances in the evidentiary basis for mechanical embolectomy are increasing the number of patients treated with this therapy. A key part of the therapeutic arsenal in many patients treated with interventional techniques has been concurrent intravenous thrombolysis. We consider whether this paradigm warrants change.
