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| CASE REPORT |
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| Year : 2017 | Volume
: 3
| Issue : 3 | Page : 178-180 |
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A case of mobile right ventricular thrombus with massive pulmonary thromboembolism
Jaywant M Nawale, Ajay S Chaurasia, Digvijay Deeliprao Nalawade, Nikhil A Borikar
Department of Cardiology, TNMC and BYL Nair Ch. Hospital, Mumbai, Maharashtra, India
| Date of Web Publication | 1-Feb-2018 |
Correspondence Address:
Dr. Digvijay Deeliprao Nalawade
Department of Cardiology, TNMC and BYL Nair Ch. Hospital, 18, ICCU, Ground Floor, OPD Building, Mumbai Central, Mumbai - 400 008, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jpcs.jpcs_54_17
In patients with pulmonary thromboembolism, right heart thrombi are uncommon or underdiagnosed. They may form in situ or arise due to migration from the peripheral venous system. Their presence in pulmonary embolism indicates a grave prognosis and complicates treatment decisions. We report a case of mobile right ventricular thrombus with massive pulmonary thromboembolism who had a rapid fatal course despite early treatment.
Keywords: Pulmonary thromboembolism, right heart thrombi, right ventricle
How to cite this article:
Nawale JM, Chaurasia AS, Nalawade DD, Borikar NA. A case of mobile right ventricular thrombus with massive pulmonary thromboembolism. J Pract Cardiovasc Sci 2017;3:178-80 |
How to cite this URL:
Nawale JM, Chaurasia AS, Nalawade DD, Borikar NA. A case of mobile right ventricular thrombus with massive pulmonary thromboembolism. J Pract Cardiovasc Sci [serial online] 2017 [cited 2023 Jun 4];3:178-80. Available from: https://www.j-pcs.org/text.asp?2017/3/3/178/224488 |
| Introduction | |  |
Right heart thrombi are uncommon in patients presenting with acute pulmonary embolism and their incidence is around 4%–18%.[1] Their presence indicates increased mortality as compared to pulmonary embolism alone. De Vrey et al. reported a mortality of >44%, while Rose et al. in a meta-analysis reported mortality of 27%.[2],[3] Due to lack of strong evidence, there is no clear consensus regarding the treatment of such cases; however, urgent treatment in the form of thrombolysis, anticoagulation, or surgical embolectomy is warranted with variable success and survival rates.
| Case Report | | |
A 34-year-old young male with no comorbidities presented with the complaints of sudden onset dyspnea at rest and presyncope for 1 day. With this, he was admitted in another hospital and diagnosed to have pulmonary thromboembolism on computed tomography (CT) pulmonary angiography and thereafter referred to our institute for further management. On examination, he had tachypnea (32 breaths/min), tachycardia (120 beats/min), and desaturation (SpO2 = 89% on room air). Blood pressure was 90/60 mmHg. Cardiovascular system examination revealed loud P2. Respiratory system examination revealed normal breath sounds. Echocardiography (ECG) revealed sinus tachycardia with right ventricular strain pattern in V1–V2. Chest X-ray showed normal lung fields. Bedside transthoracic two-dimensional (2D) ECG revealed dilated right atrium and ventricle with a large mobile thrombus in the right ventricle [Figure 1] and [Figure 2]. CT pulmonary angiography revealed saddle thrombus at pulmonary artery bifurcation with bilateral filling defects distally suggestive of massive pulmonary embolism. There were no signs suggestive of deep vein thrombosis. | Figure 1: Two-dimensional echocardiography apical four-chamber view showing dilated right atrium and ventricle with mobile 22 mm × 15 mm lobulated thrombus.
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 | Figure 2: Two-dimensional echocardiography parasternal short-axis view showing dilated right ventricle with large lobulated thrombus.
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He was immediately started on nasal oxygenation, intravenous fluids, and inotropes. Thrombolysis was initiated with streptokinase (250,000 units bolus over 30 min followed by 100,000 unit/h infusion). However, after 4 h of starting thrombolysis, his condition deteriorated. He was put on mechanical ventilation. However, despite all efforts had a fatal outcome.
| Discussion | | |
The presence of a right ventricular clot in pulmonary embolism prognosticates increased mortality as compared to pulmonary embolism alone. de Vrey et al. reported the incidence of pulmonary embolism as 97% and mortality over 44% in patients with mobile right heart thrombus.[2] Rose et al. in a meta-analysis reported an overall mortality rate of 27.1%.[3] In a study by Torbicki et al., cases of the right heart thrombus had twice the mortality rate as compared to pulmonary embolism alone.[1]
Thrombi in the right heart chambers may form in situ or arise from peripheral venous clots that get stuck on their transit to lungs.[4] Based on 2D ECG, the European Working Group on ECG identified three patterns of the right heart thrombi.[5] Type A thrombi are highly mobile, worm-like in shape and are supposed to be dislodged peripheral venous clots. Due to their extreme mobility, patients with Type A clots are at high risk with early mortality of 42%.[5] Type B thrombi are more or less immobile, usually found attached to the right atrial or ventricular wall indicating their in situ formation and are thus morphologically similar to the left heart thrombi. They belong to the low-risk group with a mortality of 4%.[5] Type C thrombi are rare and share characteristics of both. They are similar in appearance to a myxoma, are highly mobile, and have an early mortality rate intermediate between the above two types. In our case, 2D ECG revealed a highly mobile large lobulated mass measuring 22 mm × 15 mm in the right ventricle [Figure 1] and [Figure 2] with a pedicle that seemed to be attached to the ventricular septum, indicating Type C thrombus.
As per literature, there is no clear consensus regarding the treatment of mobile right heart thrombus with pulmonary embolism. Treatment options include anticoagulation, thrombolysis, and embolectomy. The success and survival rates of each approach vary depending on the patient's clinical status.[6] In a meta-analysis, Rose et al. reported mortality rates associated with no therapy, anticoagulation therapy, surgical embolectomy, and thrombolysis as 100.0%, 28.6%, 23.8%, and 11.3%, respectively.[3] However, Chartier et al. reported that there was no significant difference between these therapeutic approaches in terms of in-hospital mortality.[7]
Thrombolysis is a relatively simple, fast, and effective treatment option with numerous advantages, including acceleration of pulmonary reperfusion, early reduction in pulmonary hypertension with consequent improvement of the right ventricular function and possibility of dissolving the thrombus at all sites at the same time.[8],[9] Various studies have used thrombolysis as a successful preferred option while treating such cases.[1],[3],[10] Thrombolysis, however, has risks of bleeding and the possibility of the clot dislodging and distally embolizing to the already compromised pulmonary circulation which could be fatal.
Anticoagulation with heparin alone is assumed to be slow and inadequate in such life-threatening situations. Anticoagulation alone can be considered in hemodynamically stable patients with high individual risk of bleeding and operation-related mortality.[11] In a study by Barrios et al., however, there was no significant difference found between reperfusion therapy and anticoagulation for mortality and bleeding while treating such patients.[12]
Surgical embolectomy can be considered as a preferred treatment option, especially for hemodynamically unstable cases in which thrombolysis is contraindicated or in the presence of large clot wherein the risk of embolization is high. However, lack of easy availability, inability to simultaneously remove the pulmonary clots beyond proximal larger branches, and associated high mortality are its limitations.[7] Percutaneous treatments can be used but sufficient evidence is still lacking.
While treating our case surgical embolectomy was thought of as an alternative because the thrombus was large, mobile, and had risk of distal embolization with thrombolysis or anticoagulation. However, due to patient's hemodynamic instability and lack of surgical expertise, the decision was made to reperfuse the patient which was unsuccessful.
| Conclusion | | |
The presence of the right heart thrombus in patients with pulmonary thromboembolism is uncommon, indicates grave prognosis and influences treatment decisions. This underscores the importance of performing simple bedside investigation like 2D ECG in these patients. Thrombolysis, anticoagulation, and embolectomy are the available treatment options with variable success and survival rates with pros and cons of each. Lack of prospective randomized studies further creates therapeutic dilemma wherein various factors such as patient's hemodynamic stability, risk of hemorrhage, availability of surgical expertise, and operation-related mortality should be considered while treating such cases.
Acknowledgment
The authors would like to thank Rajendra V. Chavan MD, DM, Kshitij Bedmutha MD, DM, Shrikant Dhanwale MD, DM, Meghav Shah MD, DM.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 2. | de Vrey EA, Bax JJ, Poldermans D, van der Wall EE, Holman ER. Mobile right heart thrombus and massive pulmonary embolism. Eur J Echocardiogr 2007;8:229-31. [ PUBMED] |
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| 4. | Casazza F, Bongarzoni A, Centonze F, Morpurgo M. Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism. Am J Cardiol 1997;79:1433-5. [ PUBMED] |
| 5. | Kronik G. The European cooperative study on the clinical significance of right heart thrombi. Eur Heart J 1989;10:1046-59. |
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| 7. | Chartier L, Béra 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. |
| 8. | Levine MN. Thrombolytic therapy in acute pulmonary embolism. Can J Cardiol 1993;9:158-9. [ PUBMED] |
| 9. | Goldhaber SZ. Thrombolysis for pulmonary embolism. Prog Cardiovasc Dis 1991;34:113-34. [ PUBMED] |
| 10. | Pierre-Justin G, Pierard LA. Management of mobile right heart thrombi: A prospective series. Int J Cardiol 2005;99:381-8. [ PUBMED] |
| 11. | Português J, Calvo L, Oliveira M, Pereira VH, Guardado J, Lourenço MR, et al. Pulmonary embolism and intracardiac type A thrombus with an unexpected outcome. Case Rep Cardiol 2017;2017:9092576. |
| 12. | Barrios D, Rosa-Salazar V, Jiménez D, Morillo R, Muriel A, Del Toro J, et al. Right heart thrombi in pulmonary embolism. Eur Respir J 2016;48:1377-85. |
[Figure 1], [Figure 2]
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