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Cardiovascular Disease |

Management of Massive Pulmonary Embolism With Right Heart Emboli-in-Transit

Eugene Shostak*, MD; Olumayowa Abe, MD
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NYPH-Weill Cornell Medical Center, New York, NY


Chest. 2012;142(4_MeetingAbstracts):115A. doi:10.1378/chest.1357295
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Abstract

SESSION TYPE: Cardiovascular Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: The presence of mobile clots in right cardiac chambers identified on transthoracic echocardiogram (TTE) suggests a severe form of pulmonary embolism (PE). We present two cases of massive PE with mobile thrombi of the right heart.

CASE PRESENTATION: CASE 1: A 76 year old man presented with a near syncope and progressive exertional dyspnea. The patient recently underwent hip replacement surgery. On arrival his blood pressure was 80/50 mm Hg, heart rate 125/minute, and oxygen saturation 86% on room air. Physical examination elicited signs of right heart failure. CT angiogram revealed bilateral subsegmental pulmonary emboli. TTE showed a 4.0cm x 1.5cm right atrial mass that prolapsed through the tricuspid valve. Thrombolytic therapy was instituted with alteplase infusion, followed by anticoagulation with heparin. Repeat echocardiogram 24 hours later revealed resolution of right atrial mass and near normalization of right ventricular function. Patient underwent remarkable recovery and was discharged on warfarin. CASE 2: A 76 year old man with a history of bladder cancer presented with syncope. Admission vital signs and physical examination were similar to case #1. CT angiogram demonstrated intraluminal filling defects in the main pulmonary artery trunk. TTE unveiled a 6.5cm serpentine mass in the right atrium that prolapsed through the tricuspid valve. Patient underwent surgical embolectomy and right atrial thrombectomy. His post-operative course was uneventful and he was discharged on enoxaparin.

DISCUSSION: Right heart thromboemboli (RHTE), also known as clots-in-transit, are formed when clots from lower extremities become temporarily wedged in the right cardiac chambers. RHTE is an independent risk factor for hemodynamic compromise and a higher rate of mortality. Surgical embolectomy is an effective treatment option for central pulmonary emboli resulting in hemodynamic compromise, with or without an accompanying clot in transit. Thrombolysis is reserved for patients who are poor surgical candidates and for patients with distal PE. Although the effects of thrombolysis or surgical embolectomy on improving mortality in patients with PE and RHTE are controversial, the time to clot resolution and hemodynamic improvement occurs more rapidly with thrombolytics than heparin alone. The optimum treatment for patients with PE and RHTE that do not exhibit signs of hemodynamic compromise is less clear.

CONCLUSIONS: Identification of RHTE on bedside TTE may aid a clinician in choosing thrombolysis or surgical embolectomy as a treatment option for select patients with massive and submassive PE.

1) Torbicki A, et al. Right Heart Thrombi in Pulmonary Embolism. Results From the International Cooperative Pulmonary Embolism Registry. JACC. 2003;41(12):2245-2251.

DISCLOSURE: The following authors have nothing to disclose: Eugene Shostak, Olumayowa Abe

No Product/Research Disclosure Information

NYPH-Weill Cornell Medical Center, New York, NY

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