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Title Right heart thrombus in transit diagnosed by bedside ultrasound

Permalink https://escholarship.org/uc/item/13n5g2v3

Journal Journal of Emergency Medicine, 48(4)

ISSN 0736-4679

Authors Martires, JS Stein, SJ Kamangar, N

Publication Date 2015

DOI 10.1016/j.jemermed.2014.11.011

Peer reviewed

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Thank you for your assistance. The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–4, 2014 Ó Copyright 2014 Elsevier Inc. 62 Printed in the USA. All rights reserved 0736-4679/$ - see front matter 63 64 http://dx.doi.org/10.1016/j.jemermed.2014.11.011 65 66 67 68 1 69 Visual Diagnosis 70 2 71 3 in Emergency Medicine 72 4 73 5 74 6 75 7 76 8 RIGHT HEART THROMBUS IN TRANSIT DIAGNOSED BY BEDSIDE ULTRASOUND 77 9 78 10 79 11 Q3 Joanne S. Martires, MD, Susan J. Stein, MD, and Nader Kamangar, MD 80 12 81 13 Division of Pulmonary and Critical Care Medicine, Department of Medicine, UCLA-Olive View Medical Center, 82 14 UCLA Geffen School of Medicine, Sylmar, California 83 Reprint Address: 15 Nader Kamangar, MD, MS, FACP, FCCP, FCCM, Division of Pulmonary and Critical Care Medicine, Department of Medicine, 84 16 UCLA-Olive View Medical Center, UCLA Geffen School of Medicine, 14445 Olive View Drive, Room 2B-182, Sylmar, CA 91342 85 17 86 18 87 19 on exertion for approximately 12 days. His symptoms 88 20 89 21 began shortly after a 6-h flight. The patient also experienced myalgias, vomiting, and fatigue and had spent several days 90 22 INTRODUCTION 91 23 in bed with what he believed was a viral illness. 92 24 Vital signs on arrival to the emergency department 93 25 Right heart thrombi in transit represent deep venous thrombi that have mobilized and become lodged in the were as follows: heart rate: 113 beats/min (regular); blood 94 26 95 27 right heart en route to the pulmonary arteries, with the po- pressure: 101/85 mm Hg; respiratory rate: 25 breaths/ min; oxygen saturation, 93% on 4 L oxygen via nasal can- 96 28 tential to migrate and lead to additional embolic compli- 97 29 cations. Due to their increased risk for mortality, right nula. Physical examination revealed an ill-appearing man 98 30 with marked cyanosis and mottling of the lower extrem- 99 31 heart thrombi in transit represent a severe form of venous thromboembolism. In addition, in patients with patent fo- ities. Jugular venous pressure was elevated to 14 cm and 100 32 101 33 ramen ovale (PFO) or atrial septal defect (ASD), right cardiac examination revealed an increased intensity of the pulmonic component of the second heart sound. 102 34 heart thrombi in transit can lead to systemic thromboem- 103 35 bolism. Once diagnosed, right heart thrombi in transit The remainder of the physical examination was otherwise 104 36 require consideration of emergent treatment such as normal. 105 37 106 38 thrombolytics, surgical thromboembolectomy, or Complete blood count was remarkable for a leukocy- tosis of 14 and a hematocrit of 49.6%. Chemistry findings 107 39 catheter-based intervention, due to the potential of the 108 40 clot to fragment or migrate leading to further vascular were normal, with the exception of the creatinine 109 41 obstruction and hemodynamic compromise. (1.67 mg/dL). Cardiac troponin (cTnI) was mildly 110 42 elevated at 0.153 mg/mL. Electrocardiogram was 111 43 112 44 CASE REPORT remarkable for right ventricular strain. Point of care cardiac ultrasound was immediately per- 113 45 114 46 A 32-year-old man with no significant medical history formed and revealed a moderately dilated right ventricle 115 47 presented with left-sided pleuritic chest pain and dyspnea with reduced systolic function. In addition, there was a 116 48 large, mobile, snake-like echodensity within the right 117 49 118 50 atrium, extending into the right ventricle, where it appeared to be moving back and forth (Figure 1). The 119 51 Q1 Streaming video: One brief real-time video clip that accom- 120 52 panies this article is available in streaming video at www.jour- patient was immediately taken to computed tomography 121 53 nals.elsevierhealth.com/periodicals/jem. Click on Video Clip 1. (CT) pulmonary angiography, where a serpiginous 122 54 123 55 124 56 125 57 126 RECEIVED: 16 July 2014; FINAL SUBMISSION RECEIVED: 10 October 2014; 58 127 ACCEPTED: 16 November 2014 59 128 60 129 61 1

SCO 5.2.0 DTD - JEM10200_proof - 15 December 2014 - 8:47 pm - ce 2 J. S. Martires et al. 130 198 131 199 132 tion, with near normalization of the pulmonary artery 200 133 pressures. Lower-extremity ultrasonography demon- 201 134 strated an extensive left femoral vein thrombus extending 202 135 203 136 into the popliteal vein. Placement of an inferior vena cava 204 137 filter was considered, but ultimately one was not placed 205 138 because the patient was able to tolerate anticoagulation. 206 139 The patient remained hemodynamically stable and was 207 140 eventually bridged from heparin to warfarin and dis- 208 141 209 142 charged from the hospital once his international normal- 210 143 ized ratio was therapeutic. 211 144 212 145 DISCUSSION 213 146 214 147 215 148 Right heart thrombi in transit are often found in the setting 216 149 Figure 1. Bedside cardiac ultrasound showing a serpiginous, of severe bilateral PEs (1,2). Dyspnea, chest pain, and 217 150 mobile mass in the right atrium representing a right heart syncope are the most common presenting symptoms. 218 151 thrombus in transit. Patients with right heart thrombi in transit often have 219 152 higher heart rates, lower blood pressures, and exhibit 220 153 density in the right heart and a saddle pulmonary embo- 221 154 more right ventricular dysfunction compared with 222 155 lism (PE) with extension into the right and left main pul- patients who present with PE without right heart thrombi 223 156 monary artery, as well as interlobar, lobar, and segmental in transit (1). Patients can also present in cardiogenic 224 157 arteries were visualized (Figure 2). shock. The reported incidence in patients with PE is 225 158 Recombinant tissue plasminogen activator (t-PA) between 3.6% and 18% (1À3). 226 159 10 mg via intravenous bolus was immediately adminis- 227 160 The diagnosis of right heart thrombi in transit is usu- 228 161 tered, followed by 90 mg infusion over 2 h, in order ally made by echocardiography or CT pulmonary angiog- 229 162 to treat the patient’s right heart thrombus in transit and raphy. Point of care ultrasound, as in our case, can lead to 230 163 severe PE. Shortly after administration of t-PA, the pa- a more prompt diagnosis. On these imaging modalities, a 231 164 tient’s oxygen saturation improved to 99% on room air right heart thrombus in transit has been described as a 232 165 and his extremities became warm and well-perfused. 233 166 highly mobile, coiled, or serpiginous mass, usually in 234 167 Upon arrival to the intensive care unit, the patient devel- the right atrium with prolapse into the ventricle (3,4). 235 168 oped an episode of epistaxis that required nasal packing. A right heart thrombus in transit is an ominous manifes- 236 169 Six hours after t-PA administration, a formal transtho- tation of venous thromboembolism that requires a more 237 170 racic echocardiogram showed complete resolution of aggressive and emergent management approach, as nearly 238 171 the right heart thrombus in transit (Figure 3). 239 172 all deaths occur within the first 24 h (5).However,the 240 173 The patient continued to do well clinically and was optimal treatment remains somewhat controversial. 241 174 placed on anticoagulation with heparin. Repeat formal Thrombolytics and surgical embolectomy are the most 242 175 echocardiography showed marked improvement of right described and well-validated treatment modalities. Suc- 243 176 ventricular dilatation and right ventricular systolic func- cessful treatment with anticoagulation alone has been 244 177 245 178 246 179 247 180 248 181 249 182 250 183 251 184 252 185 253 186 254 187 255 188 256 189 257 190 258 191 259 192 260 193 261 194 262 195 Figure 2. Computed tomography pulmonary angiogram demonstrating (A) serpiginous density in the right heart and (B) saddle 263 pulmonary embolus. 196 264 197 265

SCO 5.2.0 DTD - JEM10200_proof - 15 December 2014 - 8:47 pm - ce Right Heart Thrombus in Transit 3 266 334 267 335 268 336 269 337 270 338 271 339 272 340 273 341 274 342 275 343 276 344 277 345 278 346 279 347 280 Figure 3. (A) Initial bedside cardiac ultrasound demonstrating a serpiginous mass in the right atrium and right ventricle. (B) Trans- 348 281 thoracic echocardiogram done 6 h after the administration of thrombolytics demonstrating complete resolution of right heart 349 282 thrombus in transit. 350 283 351 284 352 285 documented, but there is substantial evidence that this to the sheath using the negative pressure from a syringe 353 286 Q2 treatment is inadequate and, in some studies, equivocal or a basket device is used to capture the thrombus and 354 287 to no treatment (1,4). In addition, anticoagulation may move it into the inferior vena cava (IVC) and an IVC 355 288 have a slow onset of action and lead to fragmentation filter is placed, in theory preventing the thrombus from 356 289 and embolization of a right heart thrombus in transit. re-entering the right heart. Transesophageal echocardiog- 357 290 358 291 Although the presence of right heart thrombi in transit raphy may be used to provide visualization during the pro- 359 292 is associated with increased mortality, little is known cedure. The risks of percutaneous retrieval include further 360 293 about optimal management of this difficult clinical situa- embolization of the right heart thrombus or perforation of 361 294 tion. In addition to anticoagulation, there are several other vital cardiovascular structures. Although this strategy has 362 295 therapeutic options that should be considered for the been shown to be technically feasible, it is not meant to 363 296 364 297 management of right heart thrombi in transit. These in- be an alternative to thrombolytics or surgery and its pur- 365 298 cludes systemic thrombolysis, surgical embolectomy, pose is to serve as a salvage treatment for those with con- 366 299 and catheter-based treatments. Thrombolytics have been traindications to both of these treatments. 367 300 shown to dissolve right heart thrombi in transit and lead The diagnosis of right heart thrombi in transit carries 368 301 to improvements in right heart strain, pulmonary vascular poor prognostic significance. In-hospital mortality has 369 302 370 303 resistance, and pulmonary hemodynamics. Urokinase, been reported to be as high as 45% (10). Treatment with 371 304 streptokinase, or t-PA are typically used; the dose of t- surgery or thrombolytics has been shown to significantly 372 305 PA that is typically used for massive PE is 100 mg over reduce mortality when compared to treatment with antico- 373 306 2h(6). Treatment monitoring can be done effectively agulation alone. There are no randomized controlled trials 374 307 by serial echocardiography. Most right heart thrombi in comparing surgery to thrombolytics but, in a meta- 375 308 376 309 transit resolve within 2 h of administration of thrombo- analysis, there was improved survival rate in patients 377 310 lytics, but occasionally have been known to take up to treated with thrombolytics (4). Patients with right heart 378 311 12 or even 24 h to resolve (7). The major risk associated thrombi in transit who survive hospitalization generally 379 312 with thrombolytic therapy is significant bleeding and it have a favorable prognosis after discharge. 380 313 should therefore be avoided in patients with contraindica- In cases of acute PE, evidence of right heart thrombi in 381 314 382 315 tions, including recent surgery or stroke. transit on bedside echocardiography portends a poor 383 316 Surgical embolectomy is considered a classic treat- prognosis and identifies patients who may benefit from 384 317 ment for right heart thrombi in transit and may be the immediate, aggressive treatment modalities. The detec- 385 318 treatment of choice when the need for a repair of a PFO tion of right heart thrombi in transit during point of care 386 319 simultaneously exists to prevent paradoxical emboli, or echocardiography may have significant diagnostic and 387 320 388 321 when thrombolytic therapy is contraindicated (5). Surgi- therapeutic implications. Additionally, formal echocardi- 389 322 cal embolectomy allows for rapid removal of thrombi ography may identify a PFO or ASD, which can further 390 323 from the right heart and both of the pulmonary arteries. increase the morbidity and mortality associated with right 391 324 This procedure has the potential advantage of repairing heart thrombi in transit. Although the optimal therapy re- 392 325 a PFO or a septal defect, if present. mains controversial, thrombolysis and embolectomy 393 326 394 327 There have been case reports documenting the use of appear effective, while anticoagulation alone appears 395 328 percutaneous catheterization to retrieve right heart thrombi insufficient. The risks and benefits of thrombolytics, sur- 396 329 in transit (8,9). During this procedure, a sheath is gical embolectomy, and catheter-based interventions 397 330 introduced into the femoral vein and into the right heart. should be considered when selecting the ideal therapeutic 398 331 From there, the right heart thrombus in transit is attached modality for this high-risk subset of patients with PE. 399 332 400 333 401

SCO 5.2.0 DTD - JEM10200_proof - 15 December 2014 - 8:47 pm - ce 4 J. S. Martires et al. 402 470 403 471 404 REFERENCES 7. Ferrari E, Benhamou M, Berthier F, et al. Mobile thrombi of the 472 405 right heart in pulmonary embolism: delayed disappearance after 473 406 thrombolytic treatment. Chest 2005;127:1051–3. 474 1. Torbicki A, Galie N, Covezzoli A, et al. Right heart thrombi in 8. Richartz BM, Werner GS, Ferrari M, et al. Non-surgical extraction 407 475 pulmonary embolism: results from the International Cooperative of right cardiac ‘‘thrombus in transit.’’ Catheter Cardiovas Interv 408 Embolism Registry. J Am Coll Cardiol 2003;41:2245–51. 2000;51:316–9. 476 409 2. Casazza F, Bongarzoni A, Centonze F, et al. Prevalence and prog- 9. Mukharji J, Perterson JE. Percutaneous removal of a large mobile 477 410 nostic significance of right-sided cardiac mobile thrombi in acute right atrial thrombus using a basket retrieval device. Catheter Car- 478 411 massive pulmonary embolism. Am J Cardiol 1997;79:1433–5. diovasc Interv 2000;51:479–82. 479 412 3. Farfel Z, Schecter M, Vered Z, et al. Review of echocardiographi- 10. Chartier L, Be´ra J, Delomez M, et al. Free- floating thrombi in the 480 cally diagnosed right heart entrapment of pulmonary emboli-in- 413 right heart: diagnosis, management, and prognostic indexes in 38 481 transit with emphasis on management. Am Heart J 1987;113:171–8. consecutive patients. Circulation 1999;99:2779–83. 414 4. Rose PS, Punjabi NM, Pearse DB. Treatment of right heart throm- 482 415 boemoli. Chest 2002;121:806–14. 483 416 5. Chapoutot L, Nazeyrollas P, Metz D, et al. Floating right heart 484 417 thrombi and pulmonary embolism: diagnosis, outcome, and thera- SUPPLEMENTARY DATA 485 418 peutic management. Cardiology 1996;87:169–74. 486 419 6. Greco F, Bisignani G, Serafini O, et al. Successful treatment of right Supplementary data related to this article can be found 487 420 heart thromboemboli with IV recombinant tissue-type plasminogen online at http://dx.doi.org/10.1016/j.jemermed.2014.11. 488 421 activator during continuous echocardiographic monitoring: a case 489 series report. Chest 1999;116:78–82. 011. 422 490 423 491 424 492 425 493 426 Streaming video: One brief real-time video clip that accompanies this article is avail- 494 427 able in streaming video at www.journals.elsevierhealth.com/periodicals/jem. Click on 495 428 Video Clip 1. 496 429 497 430 498 431 499 432 500 433 501 434 502 435 503 436 504 437 505 438 506 439 507 440 508 441 509 442 510 443 511 444 512 445 513 446 514 447 515 448 516 449 517 450 518 451 519 452 520 453 521 454 522 455 523 456 524 457 525 458 526 459 527 460 528 461 529 462 530 463 531 464 532 465 533 466 534 467 535 468 536 469 537

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