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A floating thrombus of the right ventricle in severe massive pulmonary embolism
American Journal of Emergency Medicine (2008) 26, 1071.e1–1071.e2
www.elsevier.com/locate/ajem
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 department (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, 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
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 floating “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 enlargement (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 desaturation (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 ventricular thrombi was 4% to 18% in patients with pulmonary embolism in previous studies [1,2,7,8]. An echocardiographic 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).
1071.e2
Case Report 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] Fig. 2 Contrast-enhanced computed tomographic scan at the level of pulmonary trunk demonstrates large thrombi in bilateral pulmonary arteries (arrows).
doi:10.1016/j.ajem.2008.03.045
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%). PierreJustin 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 hemodynamic 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].
References [1] Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999;353:1386-9. [2] Torbichi A, Galie N, Covezzoli A, et al. Right heart thrombi in pulmonary embolism. J Am Coll Cardiol 2003;41:2245-51. [3] Hunter JJ, Johnson KR, Karagianes TG, et al. Detection of massive pulmonary embolus-in-transit by transesophageal echocardiography. Chest 1991;100:1210-4. [4] Redberg RF, Hecht SR, Berger M. Echocardiographic detection of transient right heart thrombus: now you see it, now you don’t. Am Heart J 1991;122:862-4. [5] Pierre-Justin G, Pierard LA. Management of mobile right heart thrombi: a prospective series. Int J Cardiol 2005;99:381-8. [6] Chapoutot L, Nazeyrollas P, Metz D, et al. Floating right heart thrombi and pulmonary embolism: diagnosis, outcome and therapeutic management. Cardiology 1996;87:169-74. [7] Chartier L, Bara J, Delomez M, et al. Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation 1999;99:2779-83. [8] Casazza F, Bongarzoni A, Centonze F, et al. Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism. Am J Cardiol 1997;79:1433-5. [9] Ferrari E, Benhamou M, Berthier F, et al. Mobile thrombi of the right heart in pulmonary embolism: delayed disappearance after thrombolytic treatment. Chest 2005;121:1051-3.
www.elsevier.com/locate/ajem
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 department (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, 0735-6757/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
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 floating “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 enlargement (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 desaturation (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 ventricular thrombi was 4% to 18% in patients with pulmonary embolism in previous studies [1,2,7,8]. An echocardiographic 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).
1071.e2
Case Report 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] Fig. 2 Contrast-enhanced computed tomographic scan at the level of pulmonary trunk demonstrates large thrombi in bilateral pulmonary arteries (arrows).
doi:10.1016/j.ajem.2008.03.045
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%). PierreJustin 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 hemodynamic 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].
References [1] Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999;353:1386-9. [2] Torbichi A, Galie N, Covezzoli A, et al. Right heart thrombi in pulmonary embolism. J Am Coll Cardiol 2003;41:2245-51. [3] Hunter JJ, Johnson KR, Karagianes TG, et al. Detection of massive pulmonary embolus-in-transit by transesophageal echocardiography. Chest 1991;100:1210-4. [4] Redberg RF, Hecht SR, Berger M. Echocardiographic detection of transient right heart thrombus: now you see it, now you don’t. Am Heart J 1991;122:862-4. [5] Pierre-Justin G, Pierard LA. Management of mobile right heart thrombi: a prospective series. Int J Cardiol 2005;99:381-8. [6] Chapoutot L, Nazeyrollas P, Metz D, et al. Floating right heart thrombi and pulmonary embolism: diagnosis, outcome and therapeutic management. Cardiology 1996;87:169-74. [7] Chartier L, Bara J, Delomez M, et al. Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation 1999;99:2779-83. [8] Casazza F, Bongarzoni A, Centonze F, et al. Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism. Am J Cardiol 1997;79:1433-5. [9] Ferrari E, Benhamou M, Berthier F, et al. Mobile thrombi of the right heart in pulmonary embolism: delayed disappearance after thrombolytic treatment. Chest 2005;121:1051-3.