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Resolution of right atrial thrombus following anticoagulation
International Elsevier CARD10
Journal of Cardiologv,
27 (1990) 269-211
10551
Brief Reports
Resolution of right atria1 thrombus following anticoagulation Sudhir Kushwaha
’ and Ewart M. Jepson
’ Deparrmeni of Cardrologv, Harejield Hospital, Harefield, Middlesex,
li. K.; ’ Department London, U.K.
2
of Cardiology, Central Middlesex
Hospital,
(Received 12 October 1989: revision accepted 8 November 1989)
A man with congestive heart failure, atrial fibrillation and increasing dyspnoea on exertion was shown to have a large right atrial thrombtts and multiple pulmonary emboli. The patient was anticoagulated and a subsequent echocardiogram showed that the thrombus was no longer present. This report demonstrates the need for echocardiography in patients presenting with pulmonary emboli and questions the value of anticoagulation in patients with intracavitary thrombi. Key words:
Right atria1 thrombus;
Anticoagulation
Introduction A patient is reported in whom a large mobile thrombus in the right atria1 cavity was demonstrated. Thrombus in the right atrium or ventricle is rare [l], although thrombosis of the left side of the heart is quite common and well recognized. In this patient, the thrombus may have been responsible for the presentation of multiple pulmonary emboli. Case Report A 72-year-old man was admitted with a four-month history of increasing dyspnoea and peripheral oedema. On examination he was cyanosed. There was rapid atria1 fibrillation. His blood pressure was 120/80 and the jugular venous pressure was markedly elevated. A third heart sound was present and there was peripheral oedema to the mid-thigh. Examination of the chest suggested a right pleural effusion and bilateral crepitations were noted. The chest X-ray confirmed the pleural effusion and pulmonary oedema. An electrocardiogram showed rapid atria1 fibrillation and left bundle branch block. Initial
Correspondence to: Dr. S. Kushwaha, Dept. of Cardiology, Harefield Hospital, Harefield, Middlesex UB9 6JH, U.K. 0167-5273/90/$03.50
treatment consisted of intravenous frusemide, digoxin and antibiotics. An echocardiogram revealed the presence of a large, lobulated, freely mobile and continually rotating mass in the right atrium (Fig. 1). The dimensions of the mass were 2.1 X 2.3 cm. It was suggestive of a thrombus because of the free rotation and the lack of a visible stalk. A ventilation-perfusion scan confirmed multiple pulmonary embolic disease. The patient was anticoagulated with warfarin, stabilized and discharged. At this time the thrombus was still visible and its dimensions were unchanged. Two months later, he was readmitted with deteriorating cardiac failure. A repeat echocardiogram showed that the thrombus was no longer visible (Fig. 2). Despite treatment he died soon after admission. A repeat ventilation-perfusion scan did not suggest further embolisation to the lungs.
Discussion What is particularly interesting about this case is the complete resolution of a thrombus of such volume with anticoagulant treatment alone. Although previous reports have described a decrease in size of thrombi, complete resolution is unusual. A recent review [l] examined the 28 cases of right cardiac cavity thrombi reported to date. In this review, nine of the 28 cases had surgical treatment with good results. Of the four pa-
0 1990 Elsevier Science Publishers B.V. (Biomedical Division)
270
Fig. 1. Four-chamber
apical view at diagnosis
tients who were anticoagulated with heparin two had a favourable outcome. The poor outcome in patients treated by anticoagulation, however, may have reflected their poor pretreatment condition. Corman et al. [2] reported eight cases of right atria1 thrombus and suggested that surgery is the treatment of choice in patients who are suitable as the risk of further emboli is removed. Right atria1 masses are rare echocardiographic findings and, prior to the use of echocardiography, were usually found at autopsy. In one autopsy study, right heart thrombi were detected almost as frequently as were left heart thrombi [3]. Most patients with right atria1 thrombi present with pulmonary emboli [1,2,4]. This gives rise to gradual or sudden deterioration in respiratory function representing microemboli or massive pulmonary embolism [5]. In our case, microemboli
showing
thrombus
in the right atrium
thrown off from the right atria1 thrombus may have been responsible for the presentation of the patient and his subsequent deterioration. The case illustrates that anticoagulation may cause fragmentation of intracavitary thrombi and shows the importance of examining the right cardiac cavities in patients presenting with deterioration in respiratory function.
References
Grollier G, Gerard JL. Commeau P, Bertrand JH, Potier JC. Right cardiac cavity thrombi: echocardiographic diagnosis and therapeutic indications. Report of two cases and review of the literature. Can J Cardiol 1986;2:68-75. Corman C. Roudaut R, Gosse P, Billes MA, Besse P. Dallocchio M. Right atria1 thrombosis: echocardiographic features
Fig. 2. Echocardiographic
appearance
at second admission
and management. Results in eight cases. Arch Ma1 Coeur 1986;79:464-471. CF. Mural thrombi in the heart. Am Heart J 3 Garvin 1941;21:713-720. 4 Van Kuyk M. Mols P, Englert M. Right atria1 thrombus
showing
no visible thrombus.
leading to pulmonary embolism. Br Heart .I 1984;51:462464. 5 Starkey JR, De Bono DP. Echocardiographic identification of right-sided cardiac intracavity thromboembolus in massive pulmonary embolism. Circulation 1982;66:1322-1325.
Journal of Cardiologv,
27 (1990) 269-211
10551
Brief Reports
Resolution of right atria1 thrombus following anticoagulation Sudhir Kushwaha
’ and Ewart M. Jepson
’ Deparrmeni of Cardrologv, Harejield Hospital, Harefield, Middlesex,
li. K.; ’ Department London, U.K.
2
of Cardiology, Central Middlesex
Hospital,
(Received 12 October 1989: revision accepted 8 November 1989)
A man with congestive heart failure, atrial fibrillation and increasing dyspnoea on exertion was shown to have a large right atrial thrombtts and multiple pulmonary emboli. The patient was anticoagulated and a subsequent echocardiogram showed that the thrombus was no longer present. This report demonstrates the need for echocardiography in patients presenting with pulmonary emboli and questions the value of anticoagulation in patients with intracavitary thrombi. Key words:
Right atria1 thrombus;
Anticoagulation
Introduction A patient is reported in whom a large mobile thrombus in the right atria1 cavity was demonstrated. Thrombus in the right atrium or ventricle is rare [l], although thrombosis of the left side of the heart is quite common and well recognized. In this patient, the thrombus may have been responsible for the presentation of multiple pulmonary emboli. Case Report A 72-year-old man was admitted with a four-month history of increasing dyspnoea and peripheral oedema. On examination he was cyanosed. There was rapid atria1 fibrillation. His blood pressure was 120/80 and the jugular venous pressure was markedly elevated. A third heart sound was present and there was peripheral oedema to the mid-thigh. Examination of the chest suggested a right pleural effusion and bilateral crepitations were noted. The chest X-ray confirmed the pleural effusion and pulmonary oedema. An electrocardiogram showed rapid atria1 fibrillation and left bundle branch block. Initial
Correspondence to: Dr. S. Kushwaha, Dept. of Cardiology, Harefield Hospital, Harefield, Middlesex UB9 6JH, U.K. 0167-5273/90/$03.50
treatment consisted of intravenous frusemide, digoxin and antibiotics. An echocardiogram revealed the presence of a large, lobulated, freely mobile and continually rotating mass in the right atrium (Fig. 1). The dimensions of the mass were 2.1 X 2.3 cm. It was suggestive of a thrombus because of the free rotation and the lack of a visible stalk. A ventilation-perfusion scan confirmed multiple pulmonary embolic disease. The patient was anticoagulated with warfarin, stabilized and discharged. At this time the thrombus was still visible and its dimensions were unchanged. Two months later, he was readmitted with deteriorating cardiac failure. A repeat echocardiogram showed that the thrombus was no longer visible (Fig. 2). Despite treatment he died soon after admission. A repeat ventilation-perfusion scan did not suggest further embolisation to the lungs.
Discussion What is particularly interesting about this case is the complete resolution of a thrombus of such volume with anticoagulant treatment alone. Although previous reports have described a decrease in size of thrombi, complete resolution is unusual. A recent review [l] examined the 28 cases of right cardiac cavity thrombi reported to date. In this review, nine of the 28 cases had surgical treatment with good results. Of the four pa-
0 1990 Elsevier Science Publishers B.V. (Biomedical Division)
270
Fig. 1. Four-chamber
apical view at diagnosis
tients who were anticoagulated with heparin two had a favourable outcome. The poor outcome in patients treated by anticoagulation, however, may have reflected their poor pretreatment condition. Corman et al. [2] reported eight cases of right atria1 thrombus and suggested that surgery is the treatment of choice in patients who are suitable as the risk of further emboli is removed. Right atria1 masses are rare echocardiographic findings and, prior to the use of echocardiography, were usually found at autopsy. In one autopsy study, right heart thrombi were detected almost as frequently as were left heart thrombi [3]. Most patients with right atria1 thrombi present with pulmonary emboli [1,2,4]. This gives rise to gradual or sudden deterioration in respiratory function representing microemboli or massive pulmonary embolism [5]. In our case, microemboli
showing
thrombus
in the right atrium
thrown off from the right atria1 thrombus may have been responsible for the presentation of the patient and his subsequent deterioration. The case illustrates that anticoagulation may cause fragmentation of intracavitary thrombi and shows the importance of examining the right cardiac cavities in patients presenting with deterioration in respiratory function.
References
Grollier G, Gerard JL. Commeau P, Bertrand JH, Potier JC. Right cardiac cavity thrombi: echocardiographic diagnosis and therapeutic indications. Report of two cases and review of the literature. Can J Cardiol 1986;2:68-75. Corman C. Roudaut R, Gosse P, Billes MA, Besse P. Dallocchio M. Right atria1 thrombosis: echocardiographic features
Fig. 2. Echocardiographic
appearance
at second admission
and management. Results in eight cases. Arch Ma1 Coeur 1986;79:464-471. CF. Mural thrombi in the heart. Am Heart J 3 Garvin 1941;21:713-720. 4 Van Kuyk M. Mols P, Englert M. Right atria1 thrombus
showing
no visible thrombus.
leading to pulmonary embolism. Br Heart .I 1984;51:462464. 5 Starkey JR, De Bono DP. Echocardiographic identification of right-sided cardiac intracavity thromboembolus in massive pulmonary embolism. Circulation 1982;66:1322-1325.