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Right Atrial Thrombus (RAT): Break It or Let It Be!! Either Way Hope for the Best FREE TO VIEW

Parth Rali, MD; Anil Singh, MD; Eric Bihler, MD; Marvin Balaan, MD
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Allegheny General Hospital, Pittsburgh, PA

Chest. 2014;146(4_MeetingAbstracts):348A. doi:10.1378/chest.1990753
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SESSION TITLE: Miscellaneous Case Report Posters III

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: We present a case of massive serpentine right atrial thrombus in 71 year-old female undergoing chemotherapy for stage 4 poorly differentiated lung cancer.

CASE PRESENTATION: A 71 y/o caucasian woman with recently diagnosed poorly differentiated metastatic lung cancer was admitted from oncology clinic for hypotension, lethargy and weakness. Patient was septic from a urinary tract infection and was volume resuscitated. As a part of work up for hypotension, transthoracic echo was obtained. This revealed a hypermobile 5.5 cm serpentine mass in the right atrium. Full dose anticoagulation with full dose itravenous heparin was started. Cardiac MRI was obtained to better delineate mass.This revelaed a hypermobile mass originating from right atrium and traversing tricuspid valve. Contrast and T1, T2 images confirmed the mass to be a thrombus . Additional studies showed no evidence for septal defects, brain metastasis, or lower extremity thrombi. Local catheter directed thrombolysis or clot retrieval were not pursued given the location of the clot. She remained hemodynamically stable during the hospital and was discharged with an indefinite course of therapeutic enoxaparin dose.

DISCUSSION: TTE has a sensitivity of around 55-60% for RAT, which has been described as highly mobile, coiled or serpiginious masses. RAT can be seen in 9% of patients with PE (range 3-23%). TEE & Cardiac MRI can more precisely delineate mass vs thrombus. In a retrospective analysis of 177 patients, mortality rate associated with no therapy was 100%, 28.6% with anti-coagulation was 23.8, with surgical embolectomy, and 11.3 % with thrombolysis. Before thrombolysis patient should have bubble study to evaluate for PFO and Doppler for DVT. Catheter-based interventions might be options when surgery and lytic therapy are contraindicated. Because of multiple clinical factors our patient was treated with systemic anticoagulation only and had no complications

CONCLUSIONS: The management RAT should be individualized and done with multidisciplinary approach based on local availability of resources. There is no convincing evidence to support that thrombolysis is superior to systemic anticoagulation

Reference #1: Peter et al, Treatment of right heart thromboembolic Chest 2002; 121:806-814

Reference #2: Pierre-Justin G Management of Right atrial Thrombi Into J Cardio. 2005 Mar 30;99(3):381-8.

DISCLOSURE: The following authors have nothing to disclose: Parth Rali, Anil Singh, Eric Bihler, Marvin Balaan

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