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Mural Right Atrial Thrombus in Dilated Cardiomyopathy. Case Report and Literature Review
Abstracts
S242
561 Microsphere Contrast Enhancement of the Tricuspid Regurgitant Spectral Doppler Signal: Is it Still Necessary With Contemporary Scanners? D. Platts, J. Sedgwick, C. Hamilton-Craig, G. Scalia ∗ , A. Benjamin, N. Kelly, J. Sherman, R. Chamberlain, E. Fetherston, A. Putrino, M. Harten, A. Hornick, M. Ischenko, G. Mein, A. Tucker, V. Speranza, M. Rivett, D. Burstow The Prince Charles Hospital, Brisbane, Australia Background: Accurate evaluation of the tricuspid regurgitant maximal velocity (TRVmax) is important during transthoracic echocardiographic (TTE) evaluation for pulmonary hypertension (PHT). Contrast enhancement improves the spectral Doppler backscatter signal. However, its incremental benefit with contemporary scanners is less well established. Aim: Audit of patients who had a contrast echocardiogram (CE) using contemporary echo scanners and assess if the TR spectral Doppler envelope was improved following microsphere contrast administration compared to unenhanced imaging (UE). Methods: Retrospective analysis of patients who underwent UE then CE TR interrogation was performed. TR signal was graded 1 (clear-high level of confidence of interpretation and complete spectral Doppler envelope), 2 (sub-optimal with medium-low level of confidence of interpretation and incomplete envelope), 3 (poor-absent if no spectral Doppler signal or an unreliable or mostly incomplete spectral Doppler envelope). TRVmax was defined as the peak velocity that could be clearly identified. Results: 169 patients (males=120, mean age 57.6±15.2 years). TR assessed in RV inflow view and apical 4 chamber view. Mean heart rate 75.3±16.3. TRVmax could be be measured in 35.2% of patients with UE TTE (grade 1-2 in 119/338 clips) and in 56.2% with CE TTE (grade 1-2 in 190/338). Wilcoxon signed rank test demonstrated significant improvement (p<0.0001) in the TR spectral Doppler signal quality with CE TTE (mean score 2.11±0.87) vs. UE TTE (mean score 2.4±0.81). Mean TRVmax with UE TTE=2.54±0.48 m/s vs. CE TTE 2.6±0.43 m/s (p=0.008). Conclusion: In the era of contemporary scanners, CE TTE still improved the ability to detect and measure TRVmax. http://dx.doi.org/10.1016/j.hlc.2016.06.563 562 Mural Right Atrial Thrombus in Dilated Cardiomyopathy. Case Report and Literature Review M. Al-Omary ∗ , A. Boyle John Hunter Hospital/Cardiology Department, Newcastle, Australia
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A 38-year-old male with heavy alcohol intake presented with vague symptoms for 2 months. CT chest showed rightsided heart thrombi with ascites & congestive cirrhosis. This promoted echocardiography, which showed a3X3cm right atrial thrombus and dilated cardiomyopathy with poor right & left ventricular functions. His father died at the age of 48 from an unknown heart problem. He developed cardiogenic shock and was treated with inotropes and heparin. His coagulation profile was deranged due to liver disease. Cardiothoracic surgery was advised against surgical thrombectomy. He died of cardiac arrest after 2 weeks in ICU. The autopsy confirmed cardiomyopathy with pulmonary emboli & liver cirrhosis likely due to heart failure. Right heart thrombi are rare & associated with high mortality [1,2]. Most cases are associated with thromboembolic disease [3]. The ICOPER study showed 4% of patients with pulmonary embolism had right-sided heart thrombus [4]. However, there is reported case with dilated cardiomyopathy [5,6]. The diagnosis is usually made by echo [3]. There is no guide regarding the best treatment option. Anticoagulant, thrombolytic & surgery have been reproted. Thrombolysis is associated with lower mortality in registries [3,4], however, there is no prospective randomised controlled trial to guide the best treatment. Thrombolysis was not used in the patient due to coagulopathy.
Reference [1] Chartier L, et al. Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation 1999 Jun;99(21):2779–83. ISSN 1524-4539. Disponível em: < http://www.ncbi.nlm. nih.gov/pubmed/10351972 >. [2] Kinney EL, Wright RJ. Efficacy of treatment of patients with echocardiographically detected right-sided heart thrombi: a meta-analysis. Am Heart J 1989 Sep;118(3):569–73. ISSN 0002-8703. Disponível em: < http://www.ncbi.nlm. nih.gov/pubmed/2773775>. [3] ROSE PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest Mar 2002;121(3):806–14. ISSN 0012-3692. Disponível em: < http://www.ncbi.nlm. nih.gov/pubmed/11888964 >. [4] Torbicki A, et al. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol Jun 2003;41(12):2245–51. ISSN 0735-1097. Disponível em: < http://www.ncbi.nlm. nih.gov/pubmed/12821255 >. [5] Liu H. Severely dilated right atrium with spontaneous coronary sinus thrombus. Eur Heart J Dec 2014;35(48):3463. ISSN 1522-9645. Disponível em: < http://www.ncbi.nlm. nih.gov/pubmed/25189598 >. [6] Kinova E, Zlatareva N, Goudev A. Right atrial thrombus from inferior vena cava after acute cardiotoxicity of 5-fluorouracil. Cardiol J 2008;15(3):284–5. ISSN 1897-5593. Disponível em: < http://www.ncbi.nlm.nih.gov/pubmed/18651423 >.
http://dx.doi.org/10.1016/j.hlc.2016.06.564
S242
561 Microsphere Contrast Enhancement of the Tricuspid Regurgitant Spectral Doppler Signal: Is it Still Necessary With Contemporary Scanners? D. Platts, J. Sedgwick, C. Hamilton-Craig, G. Scalia ∗ , A. Benjamin, N. Kelly, J. Sherman, R. Chamberlain, E. Fetherston, A. Putrino, M. Harten, A. Hornick, M. Ischenko, G. Mein, A. Tucker, V. Speranza, M. Rivett, D. Burstow The Prince Charles Hospital, Brisbane, Australia Background: Accurate evaluation of the tricuspid regurgitant maximal velocity (TRVmax) is important during transthoracic echocardiographic (TTE) evaluation for pulmonary hypertension (PHT). Contrast enhancement improves the spectral Doppler backscatter signal. However, its incremental benefit with contemporary scanners is less well established. Aim: Audit of patients who had a contrast echocardiogram (CE) using contemporary echo scanners and assess if the TR spectral Doppler envelope was improved following microsphere contrast administration compared to unenhanced imaging (UE). Methods: Retrospective analysis of patients who underwent UE then CE TR interrogation was performed. TR signal was graded 1 (clear-high level of confidence of interpretation and complete spectral Doppler envelope), 2 (sub-optimal with medium-low level of confidence of interpretation and incomplete envelope), 3 (poor-absent if no spectral Doppler signal or an unreliable or mostly incomplete spectral Doppler envelope). TRVmax was defined as the peak velocity that could be clearly identified. Results: 169 patients (males=120, mean age 57.6±15.2 years). TR assessed in RV inflow view and apical 4 chamber view. Mean heart rate 75.3±16.3. TRVmax could be be measured in 35.2% of patients with UE TTE (grade 1-2 in 119/338 clips) and in 56.2% with CE TTE (grade 1-2 in 190/338). Wilcoxon signed rank test demonstrated significant improvement (p<0.0001) in the TR spectral Doppler signal quality with CE TTE (mean score 2.11±0.87) vs. UE TTE (mean score 2.4±0.81). Mean TRVmax with UE TTE=2.54±0.48 m/s vs. CE TTE 2.6±0.43 m/s (p=0.008). Conclusion: In the era of contemporary scanners, CE TTE still improved the ability to detect and measure TRVmax. http://dx.doi.org/10.1016/j.hlc.2016.06.563 562 Mural Right Atrial Thrombus in Dilated Cardiomyopathy. Case Report and Literature Review M. Al-Omary ∗ , A. Boyle John Hunter Hospital/Cardiology Department, Newcastle, Australia
.. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .
A 38-year-old male with heavy alcohol intake presented with vague symptoms for 2 months. CT chest showed rightsided heart thrombi with ascites & congestive cirrhosis. This promoted echocardiography, which showed a3X3cm right atrial thrombus and dilated cardiomyopathy with poor right & left ventricular functions. His father died at the age of 48 from an unknown heart problem. He developed cardiogenic shock and was treated with inotropes and heparin. His coagulation profile was deranged due to liver disease. Cardiothoracic surgery was advised against surgical thrombectomy. He died of cardiac arrest after 2 weeks in ICU. The autopsy confirmed cardiomyopathy with pulmonary emboli & liver cirrhosis likely due to heart failure. Right heart thrombi are rare & associated with high mortality [1,2]. Most cases are associated with thromboembolic disease [3]. The ICOPER study showed 4% of patients with pulmonary embolism had right-sided heart thrombus [4]. However, there is reported case with dilated cardiomyopathy [5,6]. The diagnosis is usually made by echo [3]. There is no guide regarding the best treatment option. Anticoagulant, thrombolytic & surgery have been reproted. Thrombolysis is associated with lower mortality in registries [3,4], however, there is no prospective randomised controlled trial to guide the best treatment. Thrombolysis was not used in the patient due to coagulopathy.
Reference [1] Chartier L, et al. Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation 1999 Jun;99(21):2779–83. ISSN 1524-4539. Disponível em: < http://www.ncbi.nlm. nih.gov/pubmed/10351972 >. [2] Kinney EL, Wright RJ. Efficacy of treatment of patients with echocardiographically detected right-sided heart thrombi: a meta-analysis. Am Heart J 1989 Sep;118(3):569–73. ISSN 0002-8703. Disponível em: < http://www.ncbi.nlm. nih.gov/pubmed/2773775>. [3] ROSE PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest Mar 2002;121(3):806–14. ISSN 0012-3692. Disponível em: < http://www.ncbi.nlm. nih.gov/pubmed/11888964 >. [4] Torbicki A, et al. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol Jun 2003;41(12):2245–51. ISSN 0735-1097. Disponível em: < http://www.ncbi.nlm. nih.gov/pubmed/12821255 >. [5] Liu H. Severely dilated right atrium with spontaneous coronary sinus thrombus. Eur Heart J Dec 2014;35(48):3463. ISSN 1522-9645. Disponível em: < http://www.ncbi.nlm. nih.gov/pubmed/25189598 >. [6] Kinova E, Zlatareva N, Goudev A. Right atrial thrombus from inferior vena cava after acute cardiotoxicity of 5-fluorouracil. Cardiol J 2008;15(3):284–5. ISSN 1897-5593. Disponível em: < http://www.ncbi.nlm.nih.gov/pubmed/18651423 >.
http://dx.doi.org/10.1016/j.hlc.2016.06.564