Critical Care |

“Where Did That Thing Come From?!”: Case Report of a Rapidly Migrating Right Atrial Thrombus FREE TO VIEW

Jay Patel, MD; Girish B Nair, MD; Stanislaw Klek, MD; Boshra Louka, MD; Melanie Chong, MD; Michael D’Anca, MD; Jeffrey Liu, MD; Shalinee Chawla, MD
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Winthrop University Hospital, Mineola, NY

Chest. 2013;144(4_MeetingAbstracts):322A. doi:10.1378/chest.1705269
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SESSION TITLE: Critical Care Cases

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AM

INTRODUCTION: Acute right heart failure secondary to right atrial thrombus is a life threatening condition. We present a case of obstructive shock from a migrating right atrial thrombus, which was not seen on a CT angiogram of the chest, done 10 minutes prior to the patient’s acute presentation.

CASE PRESENTATION: A 66 year old male was admitted with chief complaints of exertional dypsnea and trace hemoptysis for one week. His past medical history was significant for mitral valve prolapse. On admission, his vitals were unremarkable, except for tachycardia. Physical examination revealed bibasilar crackles and pitting pedal edema. Labs were significant for a BNP of >900pg/mL and TSH of < 0.010 ulU/mL and Free T4 of 3.58 ng/dL. EKG confirmed atrial fibrillation with rapid ventricular rate at 209bpm and was subsequently started on diltiazem drip and digoxin. A bedside thoracic echo demonstrated a severely reduced systolic function with left ventricular ejection fraction of 20-25% with dilatation of all four cardiac chambers and moderate mitral regurgitation. A CT angiogram of the chest on admission showed no evidence of PE or DVT but evidence of right heart failure. Shortly upon returning from the CT scan, patient became hypotensive and the rapid response team was activated. He was noted to be in severe right heart failure requiring emergent intubation and mechanical ventilation. Patient was also started on vasopressors to maintain blood pressure. A repeat echocardiogram at bedside revealed multiple mobile masses swirling the right atrium, extending into the right ventricle, with severely decreased systolic function, LVEF <10% and possible clot in the inferior vena cava. He was urgently given alteplase 100mg IV over 2 hours. His blood pressure improved post thrombolytic but required intra-aortic balloon pump to augment forward flow. A repeat echocardiogram the following morning demonstrated resolution of the large mobile masses with improved systolic function, LVEF=35-40%.

DISCUSSION: Right atrial thrombi that are not related to structural heart disease or catheters located in the heart are rare. However, they may present as a migrating clot from the venous system to the pulmonary circulation, known as a right heart thrombus-in-transit (1).

CONCLUSIONS: Our case demonstrates the need to maintain a high clinical suspicion of pulmonary embolus even in the setting of a negative CT angiogram (2). The usage of bedside ultrasound in the setting of a rapidly deteriorating patient can be an invaluable asset to the clinician (3).

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 1;99(21):2779-83.

Reference #2: Hogg K, et al. Diagnosis of pulmonary embolism with CT pulmonary angiography: a systematic review. Emerg Med J. 2006 Mar;23(3):172-8.

Reference #3: Manno E, et al. Deep impact of ultrasound in the intensive care unit: the "ICU-sound" protocol. Anesthesiology. 2012 Oct;117(4):801-9.

DISCLOSURE: The following authors have nothing to disclose: Jay Patel, Girish B Nair, Stanislaw Klek, Boshra Louka, Melanie Chong, Michael D’Anca, Jeffrey Liu, Shalinee Chawla

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