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Right Heart Thrombus in Transit Diagnosed by Bedside Ultrasound UCLA UCLA Previously Published Works 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 eScholarship.org Powered by the California Digital Library University of California Our reference: JEM 10200 P-authorquery-v9 AUTHOR QUERY FORM Journal: JEM Please e-mail or fax your responses and any corrections to: E-mail: [email protected] Article Number: 10200 Fax: +31 2048 52789 Dear Author, Please check your proof carefully and mark all corrections at the appropriate place in the proof (e.g., by using on-screen annotation in the PDF file) or compile them in a separate list. 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Please correct if necessary Q3 Please confirm that given names and surnames have been identified correctly. Please check this box or indicate your approval if you have no , corrections to make to the PDF file 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.
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