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Free-floating thrombus in the right heart and pulmonary embolism
International Journal of Cardiology 112 (2006) e33 – e34 www.elsevier.com/locate/ijcard
Letter to the Editor
Free-floating thrombus in the right heart and pulmonary embolism Nicolas Mansencal ⁎, Olivier Dubourg Assistance Publique - Hôpitaux de Paris, Hôpital universitaire Ambroise Paré, Service de Cardiologie, 9, avenue Charles de Gaulle, 92100, Boulogne, France Received 21 December 2005; accepted 24 February 2006 Available online 21 July 2006
Abstract We describe the case of a woman with acute pulmonary embolism and free-floating thrombus in the right heart. The diagnosis was performed using transthoracic echocardiography. The patient received urgent intravenous thrombolytic therapy with tissue plasminogen activator and vasoactive agent. This observation emphasizes the echocardiographic monitoring during thrombolysis in acute pulmonary embolism, allowing to strictly assess cardiac chamber sizes. © 2006 Elsevier Ireland Ltd. All rights reserved.
A 83-year-old woman with a previous history of paroxysmal atrial fibrillation treated with beta-blocker was admitted to our intensive care unit, with general malaise and dyspnea. Physical examination showed a respiratory rate of 30, pulse of 70, blood pressure of 85/45 mm Hg and a 1/6 systolic murmur at the left lower sternal border. The ECG depicted a sinus rhythm, a rightward axis shift, the McGinn and White pattern (S1Q3T3), an incomplete right bundle block branch and nonspecific ST segment and T-wave abnormalities. A transthoracic echocardiography was immediately performed and detected acute cor pulmonale and freefloating thrombus in the right heart (Fig. 1A and Data Supplement Movie 1) [1–3]. The diagnosis of pulmonary embolism was made and we decided not to perform any other diagnostic examination. The patient received intravenous thrombolytic therapy with tissue plasminogen activator and vasoactive agent. Iterative echocardiographic studies were performed during thrombolysis. Free-floating thrombus embolized to the pulmonary arteries between 60 and 90 min after the beginning of thrombolysis. The echocardiography initially revealed a significant increase of the acute cor pulmonale and severe right ventricular hypokinesia (Fig. 1B and Data Supplement Movie 2) [3,4]. However, this event ⁎ Corresponding author. Tel.: +33 149095619; fax: +33 149095344. E-mail address: [email protected] (N. Mansencal). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.02.018
was clinically well tolerated with blood pressure of 130– 80 mm Hg. Eight hours after thrombolysis, echocardiography revealed a significant decrease of right ventricular size (Fig. 1C and Data Supplement Movie 3). The patient was discharged from the hospital on day 7. In acute pulmonary embolism, mobile right heart thrombi require urgent aggressive therapy (thrombolysis or surgical embolectomy) [1,5]. Thrombolysis in such conditions is usually well tolerated. Interestingly, in our case, repetitive echocardiographies monitored sizes of right and left heart chambers. Right ventricular dilation was major, with all published echocardiographic abnormalities [2,6] and was initially increased after the dissolving of the thrombus. The recovery of cardiac abnormalities was accelerated using thrombolysis, even when hemodynamic setting was preserved. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ijcard.2006. 02.018. References [1] Chartier L, Bera 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.
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N. Mansencal, O. Dubourg / International Journal of Cardiology 112 (2006) e33–e34
Fig. 1. Transthoracic echocardiography in apical 4-chamber view. (A) Acute cor pulmonale and mobile right heart thrombus. (B) Increased right ventricular dilation and disappearance of the free-floating thrombus (90 min after the beginning of thrombolysis). (C) Eight hours later, improvement of right and left echocardiographic parameters, with a significant decrease of right ventricular dilation. LV = left ventricle; RA = right atrium; RV = right ventricle.
[2] Mansencal N, Joseph T, Vieillard-Baron A, et al. Comparison of different echocardiographic indices secondary to right ventricular obstruction in acute pulmonary embolism. Am J Cardiol 2003;92: 116–9. [3] Jardin F, Dubourg O, Bourdarias JP. Echocardiographic pattern of acute cor pulmonale. Chest 1997;111:209–17. [4] McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocar-
diography in acute pulmonary embolism. Am J Cardiol 1996;78:469–73. [5] Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest 2002;121:806–14. [6] Mansencal N, Redheuil A, Joseph T, et al. Use of transthoracic echocardiography combined with venous ultrasonography in patients with pulmonary embolism. Int J Cardiol 2004;96:59–63.
Letter to the Editor
Free-floating thrombus in the right heart and pulmonary embolism Nicolas Mansencal ⁎, Olivier Dubourg Assistance Publique - Hôpitaux de Paris, Hôpital universitaire Ambroise Paré, Service de Cardiologie, 9, avenue Charles de Gaulle, 92100, Boulogne, France Received 21 December 2005; accepted 24 February 2006 Available online 21 July 2006
Abstract We describe the case of a woman with acute pulmonary embolism and free-floating thrombus in the right heart. The diagnosis was performed using transthoracic echocardiography. The patient received urgent intravenous thrombolytic therapy with tissue plasminogen activator and vasoactive agent. This observation emphasizes the echocardiographic monitoring during thrombolysis in acute pulmonary embolism, allowing to strictly assess cardiac chamber sizes. © 2006 Elsevier Ireland Ltd. All rights reserved.
A 83-year-old woman with a previous history of paroxysmal atrial fibrillation treated with beta-blocker was admitted to our intensive care unit, with general malaise and dyspnea. Physical examination showed a respiratory rate of 30, pulse of 70, blood pressure of 85/45 mm Hg and a 1/6 systolic murmur at the left lower sternal border. The ECG depicted a sinus rhythm, a rightward axis shift, the McGinn and White pattern (S1Q3T3), an incomplete right bundle block branch and nonspecific ST segment and T-wave abnormalities. A transthoracic echocardiography was immediately performed and detected acute cor pulmonale and freefloating thrombus in the right heart (Fig. 1A and Data Supplement Movie 1) [1–3]. The diagnosis of pulmonary embolism was made and we decided not to perform any other diagnostic examination. The patient received intravenous thrombolytic therapy with tissue plasminogen activator and vasoactive agent. Iterative echocardiographic studies were performed during thrombolysis. Free-floating thrombus embolized to the pulmonary arteries between 60 and 90 min after the beginning of thrombolysis. The echocardiography initially revealed a significant increase of the acute cor pulmonale and severe right ventricular hypokinesia (Fig. 1B and Data Supplement Movie 2) [3,4]. However, this event ⁎ Corresponding author. Tel.: +33 149095619; fax: +33 149095344. E-mail address: [email protected] (N. Mansencal). 0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2006.02.018
was clinically well tolerated with blood pressure of 130– 80 mm Hg. Eight hours after thrombolysis, echocardiography revealed a significant decrease of right ventricular size (Fig. 1C and Data Supplement Movie 3). The patient was discharged from the hospital on day 7. In acute pulmonary embolism, mobile right heart thrombi require urgent aggressive therapy (thrombolysis or surgical embolectomy) [1,5]. Thrombolysis in such conditions is usually well tolerated. Interestingly, in our case, repetitive echocardiographies monitored sizes of right and left heart chambers. Right ventricular dilation was major, with all published echocardiographic abnormalities [2,6] and was initially increased after the dissolving of the thrombus. The recovery of cardiac abnormalities was accelerated using thrombolysis, even when hemodynamic setting was preserved. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ijcard.2006. 02.018. References [1] Chartier L, Bera 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.
e34
N. Mansencal, O. Dubourg / International Journal of Cardiology 112 (2006) e33–e34
Fig. 1. Transthoracic echocardiography in apical 4-chamber view. (A) Acute cor pulmonale and mobile right heart thrombus. (B) Increased right ventricular dilation and disappearance of the free-floating thrombus (90 min after the beginning of thrombolysis). (C) Eight hours later, improvement of right and left echocardiographic parameters, with a significant decrease of right ventricular dilation. LV = left ventricle; RA = right atrium; RV = right ventricle.
[2] Mansencal N, Joseph T, Vieillard-Baron A, et al. Comparison of different echocardiographic indices secondary to right ventricular obstruction in acute pulmonary embolism. Am J Cardiol 2003;92: 116–9. [3] Jardin F, Dubourg O, Bourdarias JP. Echocardiographic pattern of acute cor pulmonale. Chest 1997;111:209–17. [4] McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocar-
diography in acute pulmonary embolism. Am J Cardiol 1996;78:469–73. [5] Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest 2002;121:806–14. [6] Mansencal N, Redheuil A, Joseph T, et al. Use of transthoracic echocardiography combined with venous ultrasonography in patients with pulmonary embolism. Int J Cardiol 2004;96:59–63.