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Taenia Cordis
Taenia Cordis Jorge E. Schliamser, MD, and Avinoam Shiran, MD, MSc, Haifa, Israel
Free-floating right heart thrombi are rare echocardiographic findings usually encountered in patients with massive pulmonary embolism and associated with poor prognosis. We report a case of a large free-floating right heart thrombus without clinically
significant pulmonary embolism. The patient was treated conservatively with heparin and warfarin, and the thrombus resolved uneventfully. (J Am Soc Echocardiogr 2007;20:1418.e9-1418.e11.)
CASE REPORT
DISCUSSION
A
76-year-old man was admitted to the hospital for evaluation of fever and dysuria, which lasted 2 weeks. The patient had undergone mitral valve repair because of flail posterior leaflet 2 years earlier. He was treated with antibiotics with resolution of the fever, but because Escherichia coli grew in multiple blood cultures, an echocardiogram was ordered. Transthoracic followed by transesophageal echocardiography did not show vegetations, but a large free-floating wormlike thrombus was seen in the right heart (Figures 1 and 2; Videos 1 and 2). The thrombus was not attached to the right atrial or right ventricular (RV) wall, the tricuspid valve, or the inferior vena cava; it resided in the right atrium during systole (Figure 1) and migrated into the RV during diastole (Figure 2). Estimated systolic pulmonary artery pressure using the maximal tricuspid regurgitation jet velocity was 48 mm Hg, and there were no signs of RV overload. Ultrasonographic study results of the inferior vena cava, and deep pelvic and leg veins, were normal. Because the patient was asymptomatic, without dyspnea or hypoxemia, he was treated medically with intravenous heparin and warfarin. Three days later a repeated transthoracic echocardiography result was unchanged, and pulmonary ventilation-perfusion scan performed later that day showed a lobar perfusion defect in the left upper lobe with normal ventilation (Figure 3). The thrombus resolved completely on a successive study performed 6 days after the initial diagnosis. The patient remained asymptomatic, was discharged on long-term warfarin treatment, and was doing well 4 years later.
From the Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel. Reprint requests: Avinoam Shiran, MD, MSc, Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, 7 Michal St, Haifa 34362, Israel (E-mail: [email protected]). 0894-7317/$32.00 Copyright 2007 by the American Society of Echocardiography. doi:10.1016/j.echo.2007.05.011
Free-floating right heart thrombi (FFRHT) are rare echocardiographic findings that can be detected by transthoracic or transesophageal echocardiography. They appear as serpiginous wormlike echogenic masses that swirl and change form continuously within the right heart without any point of attachment to the cardiac chambers or valves (Videos 1 and 2).1 They usually represent thrombi originating from the leg or pelvic veins on transit toward the lungs.2 The prevalence of FFRHT is highest in patients with massive pulmonary embolism, RV overload, and hemodynamic compromise and was reported in 4% to 23% of cases.1,3-5 The presence of FFRHT was reported as a marker of worse prognosis in patients with pulmonary embolism, and mortality as high as 45% was reported.4 However, this determination was questioned, especially because the prevalence of FFRHT in less sick patients is unknown, as well as their prognostic significance.3-7 Treatment options of FFRHT include anticoagulation with heparin and warfarin, thrombolysis, surgical embolectomy, and percutaneous intervention, but the optimal treatment for this rare condition is unclear. Several studies suggested that heparin treatment alone is unsatisfactory in patients with pulmonary embolism and FFRHT, and that thrombolysis may be superior, but these claims were challenged.1,5-7 The optimal therapeutic strategy for subclinical pulmonary embolism with accompanying FFRHT is less clear. In our case the FFRHT was an incidental finding, the patient was asymptomatic and without hypoxemia, and there was no evidence of residual thrombi in the peripheral or central veins. As expected, the large FFRHT embolized eventually to the lungs, uneventfully. Uzan et al8 reported a similar case of FFRHT with bilateral deep vein thrombosis but without significant pulmonary embolism and a favorable outcome with heparin and warfarin treatment.
1418.e9
1418.e10 Schliamser and Shiran
Journal of the American Society of Echocardiography December 2007
Figure 1 Transesophageal deep gastric view. Large, free-floating wormlike thrombus (arrow) is seen curled up in right atrium (RA) during systole. AO, Aorta; LV, left ventricle; RV, right ventricle.
Figure 2 Same view as Figure 1 during diastole. Most of thrombus (arrow) has migrated through tricuspid valve into the right ventricle (RV). AO, Aorta; LV, left ventricle; RA, right atrium.
Journal of the American Society of Echocardiography Volume 20 Number 12
Schliamser and Shiran 1418.e11
Figure 3 Ventilation perfusion lung scan (posterior view). There is perfusion defect in left upper lobe (arrow) (A) with normal ventilation (B).
This case demonstrates that in the absence of significant prior embolic load to the lungs, large FFRHT can undergo lysis and embolize to the lungs without significant hemodynamic consequences under heparin and warfarin treatment only. REFERENCES 1. Greco F, Bisignani G, Serafini O, Guzzo D, Stingone A, Plastina F. Successful treatment of right heart thromboemboli with IV recombinant tissue-type plasminogen activator during continuous echocardiographic monitoring: a case series report. Chest 1999;116:78-82. 2. Noji Y, Kojima T, Aoyama T, Yamaguchi M, Araki T, Fujino S, et al. Images in cardiovascular medicine: free-floating thrombus in right heart and massive pulmonary embolism migrating into pulmonary artery. Circulation 2005;111:e438-9. 3. Casazza F, Bongarzoni A, Centonze F, Morpurgo M. Prevalence and prognostic significance of right-sided cardiac mobile
4.
5.
6.
7. 8.
thrombi in acute massive pulmonary embolism. Am J Cardiol 1997;79:1433-5. Chartier L, Bera J, Delomez M, Asseman P, Beregi JP, Bauchart JJ, et al. Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation 1999;99:2779-83. Torbicki A, Galie N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ. Right heart thrombi in pulmonary embolism: results from the international cooperative pulmonary embolism registry. J Am Coll Cardiol 2003;41:2245-51. Procopiou M, Perrier A. Treatment of right heart thromboemboli with IV recombinant tissue-type plasminogen activator. Chest 2000;117:920-1. Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest 2002;121:806-14. Uzan L, Detaint D, Leroy G, Phung H, Meddane M, Chiorescu I, et al. Mobile right heart thrombus with minimal pulmonary embolism: a case report [in French]. Arch Mal Coeur Vaiss 2001;94:1017-20.
Free-floating right heart thrombi are rare echocardiographic findings usually encountered in patients with massive pulmonary embolism and associated with poor prognosis. We report a case of a large free-floating right heart thrombus without clinically
significant pulmonary embolism. The patient was treated conservatively with heparin and warfarin, and the thrombus resolved uneventfully. (J Am Soc Echocardiogr 2007;20:1418.e9-1418.e11.)
CASE REPORT
DISCUSSION
A
76-year-old man was admitted to the hospital for evaluation of fever and dysuria, which lasted 2 weeks. The patient had undergone mitral valve repair because of flail posterior leaflet 2 years earlier. He was treated with antibiotics with resolution of the fever, but because Escherichia coli grew in multiple blood cultures, an echocardiogram was ordered. Transthoracic followed by transesophageal echocardiography did not show vegetations, but a large free-floating wormlike thrombus was seen in the right heart (Figures 1 and 2; Videos 1 and 2). The thrombus was not attached to the right atrial or right ventricular (RV) wall, the tricuspid valve, or the inferior vena cava; it resided in the right atrium during systole (Figure 1) and migrated into the RV during diastole (Figure 2). Estimated systolic pulmonary artery pressure using the maximal tricuspid regurgitation jet velocity was 48 mm Hg, and there were no signs of RV overload. Ultrasonographic study results of the inferior vena cava, and deep pelvic and leg veins, were normal. Because the patient was asymptomatic, without dyspnea or hypoxemia, he was treated medically with intravenous heparin and warfarin. Three days later a repeated transthoracic echocardiography result was unchanged, and pulmonary ventilation-perfusion scan performed later that day showed a lobar perfusion defect in the left upper lobe with normal ventilation (Figure 3). The thrombus resolved completely on a successive study performed 6 days after the initial diagnosis. The patient remained asymptomatic, was discharged on long-term warfarin treatment, and was doing well 4 years later.
From the Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel. Reprint requests: Avinoam Shiran, MD, MSc, Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, 7 Michal St, Haifa 34362, Israel (E-mail: [email protected]). 0894-7317/$32.00 Copyright 2007 by the American Society of Echocardiography. doi:10.1016/j.echo.2007.05.011
Free-floating right heart thrombi (FFRHT) are rare echocardiographic findings that can be detected by transthoracic or transesophageal echocardiography. They appear as serpiginous wormlike echogenic masses that swirl and change form continuously within the right heart without any point of attachment to the cardiac chambers or valves (Videos 1 and 2).1 They usually represent thrombi originating from the leg or pelvic veins on transit toward the lungs.2 The prevalence of FFRHT is highest in patients with massive pulmonary embolism, RV overload, and hemodynamic compromise and was reported in 4% to 23% of cases.1,3-5 The presence of FFRHT was reported as a marker of worse prognosis in patients with pulmonary embolism, and mortality as high as 45% was reported.4 However, this determination was questioned, especially because the prevalence of FFRHT in less sick patients is unknown, as well as their prognostic significance.3-7 Treatment options of FFRHT include anticoagulation with heparin and warfarin, thrombolysis, surgical embolectomy, and percutaneous intervention, but the optimal treatment for this rare condition is unclear. Several studies suggested that heparin treatment alone is unsatisfactory in patients with pulmonary embolism and FFRHT, and that thrombolysis may be superior, but these claims were challenged.1,5-7 The optimal therapeutic strategy for subclinical pulmonary embolism with accompanying FFRHT is less clear. In our case the FFRHT was an incidental finding, the patient was asymptomatic and without hypoxemia, and there was no evidence of residual thrombi in the peripheral or central veins. As expected, the large FFRHT embolized eventually to the lungs, uneventfully. Uzan et al8 reported a similar case of FFRHT with bilateral deep vein thrombosis but without significant pulmonary embolism and a favorable outcome with heparin and warfarin treatment.
1418.e9
1418.e10 Schliamser and Shiran
Journal of the American Society of Echocardiography December 2007
Figure 1 Transesophageal deep gastric view. Large, free-floating wormlike thrombus (arrow) is seen curled up in right atrium (RA) during systole. AO, Aorta; LV, left ventricle; RV, right ventricle.
Figure 2 Same view as Figure 1 during diastole. Most of thrombus (arrow) has migrated through tricuspid valve into the right ventricle (RV). AO, Aorta; LV, left ventricle; RA, right atrium.
Journal of the American Society of Echocardiography Volume 20 Number 12
Schliamser and Shiran 1418.e11
Figure 3 Ventilation perfusion lung scan (posterior view). There is perfusion defect in left upper lobe (arrow) (A) with normal ventilation (B).
This case demonstrates that in the absence of significant prior embolic load to the lungs, large FFRHT can undergo lysis and embolize to the lungs without significant hemodynamic consequences under heparin and warfarin treatment only. REFERENCES 1. Greco F, Bisignani G, Serafini O, Guzzo D, Stingone A, Plastina F. Successful treatment of right heart thromboemboli with IV recombinant tissue-type plasminogen activator during continuous echocardiographic monitoring: a case series report. Chest 1999;116:78-82. 2. Noji Y, Kojima T, Aoyama T, Yamaguchi M, Araki T, Fujino S, et al. Images in cardiovascular medicine: free-floating thrombus in right heart and massive pulmonary embolism migrating into pulmonary artery. Circulation 2005;111:e438-9. 3. Casazza F, Bongarzoni A, Centonze F, Morpurgo M. Prevalence and prognostic significance of right-sided cardiac mobile
4.
5.
6.
7. 8.
thrombi in acute massive pulmonary embolism. Am J Cardiol 1997;79:1433-5. Chartier L, Bera J, Delomez M, Asseman P, Beregi JP, Bauchart JJ, et al. Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation 1999;99:2779-83. Torbicki A, Galie N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ. Right heart thrombi in pulmonary embolism: results from the international cooperative pulmonary embolism registry. J Am Coll Cardiol 2003;41:2245-51. Procopiou M, Perrier A. Treatment of right heart thromboemboli with IV recombinant tissue-type plasminogen activator. Chest 2000;117:920-1. Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest 2002;121:806-14. Uzan L, Detaint D, Leroy G, Phung H, Meddane M, Chiorescu I, et al. Mobile right heart thrombus with minimal pulmonary embolism: a case report [in French]. Arch Mal Coeur Vaiss 2001;94:1017-20.