Türk Kareliyol Dem Arş 2000; 28:458-460 CASEREPORT

Surgical Treatment of Cardiogenic Shock Due to Huge Right Atrial Thrombus

Ahmet BALT ALARLI MD, Bekir Hayrettin Ş İRİN MD, Asuman KAFTAN MD* Pamukkale Universty Medical Faculty Deparimenis o.fCardiovascular Surgery and Cardiology, Denizli

DEV SAG ATRİYAL TROMBÜS NEDENiYLE and sero-sanguineous in charactcr. The story of a blunt GELiŞEN KARDiYOJENiK ŞOK VE CERRAHi chest ı rauma due to a ıraffic accidcnt 20 days ago w itlıout TEDAVİSİ any lung complication was obtained from the hospital's transfer note. ÖZET The patient was conscious and oriented. The systolic blood Kardiyojenik şok ve mu/tip/ pulmoner mikroemboliye prcssure was 65 mmHg, the pulse was regular at 130 per neden olan bir sağ atriya/ tromboemboli olgusu, nadir minute, and the respiratory rate was 20 breat lı per minutc. o lması sebebiyle bildirilmiştir. Sağ atriyumda serbestçe His neck veins were distended. The li ver was not enlarged dolaşan, diyasro/ sırasında trikiispit kapaktan sağ but tender. He had a vague calf tenderness on the right, ventrikiile prolabe olan ve sağ ventrikül g iriş (inj7ow) ve and H onıan's sign was considered positive. No pe riplı eral çıkı şmda ( outflow) tıkamklığa yol açan dii:ensiz geniş bir cdema was present. kitle iki boyutlu ekokardiyografi ile tespit edilmiş tir. Acil The ECG s lı owcd sin us tachycardia witlı T wavc invcrsion operasyona alınarak kardiyopulmoner baypasa girilmed­ in leads lll and V t-3.T lı e clıes t x-ray film sh o wed minimal en, tromboembolik materyal sağ atriyumdan başarıyla pleural cffusion at right sin us. After brea t lı i ng %50 oxygen çıkarılmıştır. Bu örnek vaka, antikoagülasyon ve trombo­ lizis gibi daha konservati.f yöntemlerden ziyade cerrahi by mask, the patient had an arıc rial POı of 69 mmHg, PCOı of 29 mmHg and pH of 7.49. The patient was imme­ miidalıalenin ne kadar etkin o/duğımu vurgulamaktadır. diately transferred to the intensive care unit where he re­ Anahtar kelimeler: Sağ atriya/ trombiis, kalp cerrahisi, mained hypotensive despite appropriate therapy. iki boyutlu ekokardiyografi Two-diıne n s i onal ec lı ocardiogram revealed a large, irregu­ lar, echo-dense mobile mass in right atrium, prolapsing through the tricuspid valve into the r i g lıt ventricle during Right-sided intracavitary cardiac thrombus, although diastole. There was no obvious point of attac h ınent of the very rare, is a recognized predictive factor of high mass to the atrial wall. The elinical di agnosis was a right atrial thrombus Icading to inflow and outflow obstruction mortali ty for massive pulmonary embolism. With and resulting in hemodynamic compromise. the availabili ty of two-dimensional echocardiogra­ After an urgent transfer to the operating theatrc, an emer­ phy, this lesion becomes an imp ortant and mor e rec­ geney sternotomy was done. A large purse-string s uture ognized entity ( 1). However, there are only few was thrcaded around the right atrial appendage for superi­ guidelines for the best management of right atrial or vena cava cannulation. When the wall of appendage was incised, a jet of blood was allowed to flush from the thrombus, and a controversy ex ists (2,3). The fo llow­ opening in an attempt to dislodge the free-floating throm­ ing case report deseribes an unusual but fortunate bus. The thrombus partially came out through the opening case of ri ght atrial thrombus that presented with car­ and reduced the blceding. lt was easily extracted with a diogenic shock and successfully treated with imme­ forceps without disintegration. Pulınon a r y a rıe ry pressure which was measured directly was found normal (1 8 diate surgical intervention without cardiopulmonary mmHg). bypass. The thrombus had the characteristic aspect of e nıbo lu s with venous origin. It was reddish-brown, and coiled. It varied from 2mm to lcm in width, and nearly 1 meter in CASE lcngth when it was untied. lt appeared to be a cast of a lower limb vein with multiple small side branches (Figure A 38 year old man was brought the emergency room with I ,2). The p a tlı olog i c findings were consistent w ith throm­ the sudden onset of dyspnea, palpitation, vague precordial boembolism. chest pain and weakness. He had been transferred from an­ other hospital because of the suspicion of hemothorax. The postoperative course was uneventful. T he colored­ There was a chest tube on his right side which had been Doppler ultrasound of the lower limbs was normal. T he inserted 2 hours before. The drainage was about 200 cc lung sean showed perfusion defeçts in all segments of right upper lobe that consisted with peripherally Joeat­ Received: 10 February, revision 2 May 2000 ed microembolisms. After the operation, the patient has Address for correspondence: Dr. Ahmet Baltalarlı , PK.283, 20100 Denizli Tlf: (0 532) 6 12 6050 Fax: (0258) 2 13 20 16 been followed periodically under warfarin treatment for a e-mail: [email protected] year.

458 A. Balralarlı er al: Surgical Treatmelli of Cardiogenic S/ıock Due ro Huge Rig/11 Arrial Tlırombus

Figure 1. Gross spcc i ıııe n or huge ıhroınbus . c xıracı cd from righı aıria l caviıy. lı was reddish, brown and !ike a coi l. 2. The coiled ıhroınbu s was undonc. lı varied from 2 ının to 1 c nı in width, and nearly 1 nı e ı cr in lcngth.

DISCUSSION thrombus, however, recurrent pulmonary embolism may be induced resulring in dire consequences (3,4). The elinical presentation of right atrial thrombus is Therapeutic clı o ic e should be determined according usually subtle, and specific manifestations frequent­ to the particular features of each elinical case. Some ly are lacking (4) . Dyspnea is the most frequent reports suggest that a nıobile nature and prolapse in­ symptom and occurs in two thirds of the patients (!). di cate that the mass is at high risk of breaking loose Chest pain , usually precordial, occurs in one third of an passing in to the pulmonary vasculature (!). When the patients (!).The physical examination usually is the diagnosis is made, immediare surgical therapy ııon s pecific , and less than one half of the patients should be considered. demonstrate signs of hypotension, elevated jugul ar venous pressure (1). The sudden development of a At the beginning of the operati on, the institution of systolic murmur or position-related cyanosis, in the cardiopulmonary bypass was planned and the punıp­ presence of known deep vein thrombosis, has been oxigenator was prepared. Because a dramatic im­ said to be suggestive of this complication, but deep provement was observed in the hemodynamic pa­ vein thrombosis is often clinically silent. The condi­ rameters, cardiopulnıonary bypass was not instituted tion is commonly associated with pulmonary embo­ and pulmonary embolectomy was not performed. lism. Ante mortem diagnosis of this condition is rare This foıtunate case appears to be the un ique because (ı ,3-5). of deli very of thrombus from incision in appendage of ri ght atrium without cardi opu l nıonary bypass. The imaging methods, including computeri zed to­ This technique may be considered less invasive be­ mography, digital substraction angiography, and cause it avoids the well-known damaging effects of routine angiograpy may prove useful in the diagno­ cardiopulmonary bypass especially on the lung sis of right atrial thrombus (5-7). However, two-di­ which has already injured by the pulmonary embo­ mensional echocardiography should be the initial di­ lism (9) . There might be a doubt about the safety of agnostic procedure (1,11). the technique for the possibility of a residual throm­ In most cases pulmonary embolizatian is completed bus. However, the gross appearance of the extracted within 1 to 3 days, sometimes within minutes to mass helped us to making a comment on disintegra­ hours, after echocardiographic diagnosis (4). The tion of th e clot. In addition, intraoperative two di­ echocardiographic detection of a right thrombo e nı­ mensional echocardiograpy may be used for clarify­ bolus, although very rare, should be considered as an ing the doubtful situations. emergency without additicnal invasive diagnostic We conclude that immediate surgical therapy should procedures. Therapeutic alternatives ineJude system­ be considered when a diagnosis of right atrial throm­ ic heparinization, systemic or l oca.ı thrombolysis, bus is made. A smail clıance may be given to the and surgical removal (8). Thrombolysis seems suc­ thrombus for spontaneous delivery from a right atrial cessful for the treatment of patients with right atrial ineision.

459 Tiirk Kareliyol Dem Arş 2000: 28: 458-460

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