Pulmonary Vascular Disease: Fellow Case Report Slide: Venous Thromboembolic Disease |

A Clot in Transit: Life Threatening Diagnosis or Incidental Finding? FREE TO VIEW

Jason Filopei, MD; Pierre Kory, MD; Navitha Ramesh, MD; Alfred Astua, MD; David Steiger, MD
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Mount Sinai Beth Israel, New York, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1147A. doi:10.1016/j.chest.2016.08.1257
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SESSION TITLE: Fellow Case Report Slide: Venous Thromboembolic Disease

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 25, 2016 at 04:30 PM - 05:30 PM

INTRODUCTION: Clots in transit (CIT), defined on ultrasound as a mobile echogenic material seen in the right atrium or ventricle is a high mortality emergency. The incidence of CIT is estimated at 4-18%; however, it's prevalence will increase due to increased use of point-of-care ultrasound (POCUS). Here we present a case of CIT from heparin induced thrombocytopenia (HIT) discovered with POCUS.

CASE PRESENTATION: A 76 year old female presented to the ICU with diabetic ketoacidosis. On hospital day five, the patient developed asymmetric lower extremity edema and a 50% decrease in platelets. Bedside compression ultrasound of the right femoral and left popliteal vein revealed thrombi (Figure 1A). Goal directed echocardiogram revealed a free floating, serpiginous hypoechoic mass in the right atrium prolapsing into a dilated and hypokinetic right ventricle (Figure 1B). Given the suspicion of HIT, anti-coagulation with argatroban was started, consultations of cardiothoracic surgery and interventional radiology were placed and thrombolytics were prepared. After review of all risks, benefits, and alternatives, the patient opted for anti-coagulation alone. A CT angiogram of the chest showed large central bilateral pulmonary embolisms (PE) (Figure 2). The patient remained hemodynamically stable and was discharged on rivaroxaban.

DISCUSSION: CIT is a phenomenon seen with PE with a mortality rate between 25 to 40%. Although no randomized data exists, registry data and and meta-analysis including Rose1 suggests that treatment solely with anticoagulation is associated with mortality rates of 40% while patients treated with thrombolytics or surgical thrombectomy have shown lower rates of 10-20%. Most recently, Koc et al showed in a multi-center registry of patients with CIT that hemodynamic compromise and not clot morphology was the most important prognostic factor2.

CONCLUSIONS: CIT is a highly controversial disease process that has proven extremely difficult to study. Due to the increasing use of POCUS in the critically ill, the complex and high risk situation of finding CIT among patients with PE will occur more frequently and require activation of an interdisciplinary team consisting of pulmonary, critical care, cardiology, cariothoracic surgery, and interventional radiology to ensure improved patient outcomes.

Reference #1: Rose et al. Treatment of right heart thromboemboli. Chest. 2002;121(3):806-14.

Reference #2: Koć M et al. Outcome of patients with right heart thrombi: the Right Heart Thrombi European Registry. ERJ. 2016;47(3):869-75.

DISCLOSURE: The following authors have nothing to disclose: Jason Filopei, Pierre Kory, Navitha Ramesh, Alfred Astua, David Steiger

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