Dear Journal of Heart and Cardiology Editor,
I hope you will find the enclosed manuscript, “Cardiopulmonary Clots- Management of Acute Pulmonary
Embolus in Association with Right Heart Thrombus: a Case Report” enlightening and worthy of sharing with your
readers in the Cardiology Research Journal.
The manuscript describes a patient we cared for in our teaching hospital. My faculty mentor, (Dr. Ali) and I
(Yaser Jbara, MD) have shared in reviewing this case as well as preparing this manuscript. Thus we meet the
criteria for authorship and will sign statements attesting authorship and releasing the copyright should our
manuscript be accepted for publication. Dr. Ali and I have no potential conflicts of interest to disclose. Our
manuscript has not previously been published nor is it under consideration elsewhere. All of our tables and
figures are original.
We are submitting our work as a case report. Our patient gave verbal consent for his de-identified medical
information to be published as a medical case report.
If you have further questions feel free to contact me; I am the lead author as well as the corresponding author.
Contact information:
Yaser Jbara, MD
Wright State University, Boonshoft School of Medicine
Department of Internal Medicine
Weber CHE Building, Second Floor
128 East Apple Street
Dayton, OH 45409-2902
Jbarayaser@yahoo.com
yaser.jbara@wright.edu
Omair Ali, MD
Wright State University, Boonshoft School of Medicine
Department of Cardiology Fellowship
Weber CHE Building, Second Floor
128 East Apple Street
Dayton, OH 45409-2902
Omairy2j@gmail.com
Phone: 937-776-5822
FAX: (937) 208-2621
Sincerely,
Yaser Jbara, MD
Internal Medicine Residency Program
Wright State University, Boonshoft School of Medicine
Cardiopulmonary Clots- Management of Acute Pulmonary Embolus in Association with Right Heart Thrombus
Abstract:
Pulmonary embolism is a common and lethal disease. It may, rarely, coexist with right heart thrombus. When it
does, it carries a high mortality risk. We describe here three patients with pulmonary embolism in association with
a right heart thrombus, their approaches to management and outcomes. All three patients had a chest CT scan and
an echocardiogram that showed RHT.
Introduction:
Right heart thrombus is a rare disease; it may coexist with pulmonary thromboembolism 4%-18%. The mortality is
up to 44%. Though no treatment guidelines for management of right heart thrombus exist, we report 3 cases of
right heart thrombus management with their outcomes.
Patient 1:
A 39 year old male with a history of deep vein thrombosis in his right lower leg, presented with sudden onset of
shortness of breath. He was unable to refill Rivaroxaban and subsequently had not been taking it for weeks. He
denied hemoptysis, fevers, chills or night sweats. His vitals were temperature of 98.3 F, respiratory rate of 29 per
minute, pulse of 87 per min, blood pressure of 143/104 mm Hg and oxygen saturation is 97% on 1 L nasal cannula.
Examination revealed clear lung auscultation and trace lower extremity edema. Cardiopulmonary examination was
otherwise normal. Basic metabolic panel and complete blood counts were within normal limits. His
electrocardiogram revealed normal sinus rhythm without acute changes. A Chest CT (Figure 1a,1b) revealed
evidence of chronic pulmonary emboli in lower lobes of both lungs. Reports also commented on acute pulmonary
emboli in the same distribution. Multiple filling defects were seen in a dilated right atrium, some of these were
peripherally located and seemed adherent to the right atrium wall. He was admitted to the hospital and placed on
heparin drip. A stat echocardiogram (Figure 1) showed ventricular septum with D-shaped conformation both at
systole and diastole (suggestive of volume and pressure overload). Ejection fraction was preserved. The right
ventricle was severely dilated. The right atrium revealed a thrombus close to the superior vena cava origin. It
measured 3.3 cm in height x 1.8 cm in width x 2.8 cm in length. Tricuspid valve was structurally normal. The right
ventricular systolic pressure was 95 mmHg (this was increased when compared to Echocardiographic parameters
which showed an RVSP of 78 mmHg six months prior). These findings were suggestive of acute cor pulmonale.
Thrombolytic agent was given. Concerns for distal embolization of right atrial thrombus into the pulmonary
circulation with thrombolysis, the decision was made to surgically intervene. Intraoperative transesophageal
echocardiogram (figure 3) delineated the right atrial mass. Right atrial thrombectomy was then performed (Video
1, Figure 4) He was continued on heparin drip and transitioned to Coumadin. His INR values were therapeutic on
discharge. In follow up the
Patient continues to fare well.
Figure 4 1
Patient 2:
A 65 year old female with history of chronic atrial fibrillation, on Rivaroxaban, presented with acute shortness of
breath. She had denied any constitutional symptoms, hemoptysis, orthopnea or paroxysmal nocturnal dyspnea.
EKG (figure 5) showed atrial fibrillation with rapid ventricular response and additionally right heart strain pattern.
A CT of the chest showed bilateral acute pulmonary embolism in the proximal portions of pulmonary artery
bifurcations (Figure 6a, 6b). She was placed on heparin for anticoagulation and Diltiazem drip for heart rate
control. A focused echocardiogram showed three masses, loosely attached to each other, close to the posterior
wall of right ventricle, without any visible attachment to any wall (Figure 7). Through interventional radiology, the
patient underwent thrombolysis with alteplase via ekosonic endovascular system (eKOS). A repeat Echocardiogram
two days later showed resolution of the right heart clots. She was discharged to the rehab center a few days later.
Patient 3
An 82 year old female with Stage IV (metastatic) Breast Cancer reported sudden onset of labored breathing at
home associated with lightheadness. Family contacted EMS. She was found via pulse oximetry to have an oxygen
saturation of 78% on room air. She was also tachycardic with pulse of 107 beats per minute and hypertensive with
blood pressures of 140/88 mm Hg. Examination revealed an elderly lady in respiratory distress. She was started on
a face mask however oxygenation did not improve adequately. She was intubated on site. A CT of the chest (figure
8a,8b) revealed large pulmonary emboli to the right and left pulmonary arteries. The right atrium and right
ventricle was noted to be enlarged. She was admitted to the intensive care unit for further care and management.
She was deemed to not be appropriate candidate for thrombolytics. She was started on intravenous heparin for
anticoagulation. An echocardiogram (figure 9,10) showed a large mobile thrombus measuring 3.2 cm x 3.8 cm,
prolapsing through the tricuspid valve into the right ventricle and back into the right atrium. Family elected to not
put her through extensive intervention or procedures. The patient continued to remain unresponsive. Her
condition progressively deteriorated until clinical death two days later.
Figure 8a CTPE highlighting Large pulmonary embolism in the right pulmonary artery
Figure 8b CTPE highlighting Large pulmonary embolism in the left pulmonary artery
Figures 9- 2D Echocardiogram in Apical 4 chamber view showing highly mobile thrombus moving from right atrium
through the tricuspid valve into the right ventricle.
Figures 10- 2D Echocardiogram in Right ventricular tilt position showing highly mobile large thrombus moving from
right ventricle through the tricuspid valve into right atrium
Discussion
Acute pulmonary embolism (APE) is a common disease and can be fatal. Approximately 300,000 to 600,000 people
are diagnosed each year in the United States. Per the center for disease control and prevention, it claims the life of
60,000-100,000 Americans annually. The incidence of right heart thrombus in pulmonary embolism is a rare
phenomenon, authors have estimated it to be present 4% to 18% in the setting of an acute pulmonary embolus (1,
2,3) with a reported mortality over 44 % (1,4,5) as they transit from legs to the pulmonary vasculature. Therefore,
it is crucial for physicians to evaluate if a right heart thrombus coexists with any patient presenting with a
pulmonary embolism, as patients are at risk for compromise of the cardiopulmonary circulation and sudden
circulatory failure [6].
Computed tomography pulmonary angiogram has been considered the definitive diagnostic imaging for detecting
pulmonary embolism. Its sensitivity to also detect a coexisting right heart thrombus is not well known. The use of
a bedside echocardiogram can offer vital clues toward the presence of pulmonary embolism. The diagnostic value
of an ultrasonographical combined strategy (echocardiography associated with venous ultrasonography) is high
and this strategy seems to be reliable in pulmonary embolism. In a patient with hemodynamic compromise, an
echocardiogram showing right ventricular (RV) dilation and impairment, with spared involvement of the ventricular
apex is the ‘McConnell sign’. This is highly suggestive of pulmonary embolism. This sign is due to the following
proposed mechanism (7). To counter the abrupt increase in afterload and equalize the regional wall stress, the
right ventricle assumes a spherical shape. The apical sparing is secondary to its tethering to a contracting and
hyperdynamic left ventricle. In a patient with shock or hypotension, the absence of echocardiographic signs of RV
overload or dysfunction practically excludes PE as a cause of hemodynamic compromise. Right heart thrombi in
transit can also be sometimes found on transthoracic echocardiography (4). Electively, or in non-high risk
situations (stable patients where mortality rates are low) it can offer prognostic information and risk stratify the
embolism. (8).
While we acknowledge that, in an isolated small to medium sized pulmonary embolus, the echocardiogram has a
low sensitivity, this does increase exponentially when dealing with a massive pulmonary embolism (9). Moreover,
if a right ventricular or right atrial thrombus is present, the sensitivity of an echocardiogram is high. The diagnosis
of acute Cor pulmonale by direct visualization of right ventricle overload, paradoxical intraventricular septal
motion and elevated pulmonary pressures is also an advantageous to echocardiogram [10]. If a trans-esophageal
echocardiography is performed, it may allow direct visualization of a pulmonary embolus in the central pulmonary
arteries and may also evaluate for the presence of a patent foramen ovale, which often harbors thrombus
travelling from right to left atrium.
As no prospective trials exist for the management of right heart thrombus in the setting of pulmonary embolism,
recognition of diagnosis is considered an emergent management requiring thrombolysis or embolectomy. Several
authors have described, that heparin alone has a mortality rate up to 100% and is not recommended as the sole
treatment. Classic treatment is surgical embolectomy. A potential advantage of surgical approach is the ability to
repair a patent foramen ovale if present, and reduce the risk of subsequent paradoxical embolism and stroke.
However, potential complications include, use of general anesthesia, cardiopulmonary bypass, and inability to
remove coexisting pulmonary thromboemboli beyond the central pulmonary arteries.
Other treatment options of thrombolysis have been described to accelerate thrombus lysis, pulmonary
reperfusion, reduce pulmonary hypertension and improve biventricular function by decreasing right ventricle–left
ventricle interdependence. Moreover, thrombolysis has the additional benefit to dissolve clots in other locations at
the same time, for example, the intracardiac thrombus, the pulmonary embolus, and the venous thrombosis.
Finally, it is a simple, rapid, widely applicable treatment, and it can be administered at the bedside. Others have
previously cautioned against the use of thrombolytic agents in type B thrombi. Thrombolytic agents may dissolve
the adherent stalk and actually promote distal embolism of these organized thrombi (11). In Patients with PFO,
fragmentation may lead to systemic embolization. Therefore, no standard treatment exists and patients may be
treated per clinical setting.
For patients with relative contraindications to both thrombolysis and embolectomy, interventional techniques
have been described, for example, Aspiration thrombectomy, thrombus fragmentation, and rheolytic
thrombectomy.
Given the high mortality rate [1,3,12] , regardless of treatment, some authors recommended embolectomy [13]
while others favored thrombolysis as a treatment [12,14] or as a therapeutic bridge to surgery [1] .
In conclusion, though right heart thrombus in the setting of acute PE is a rare phenomenon, we suggest a
minimum of non-invasive, simple bedside focused echocardiogram to look for right heart thrombus, as we
recommend management via thrombolysis or embolectomy per case by case and avoid observation or heparin
therapy alone as sole treatment for right heart thrombus in transit due to its high mortality rate. Further studies
are needed to suggest best practical diagnostic approach and management on evaluation of right heart thrombus
in the setting acute pulmonary embolism.
References
1. Chartier L, Be´ra J, Delomez M et al. Free-floating thrombi in the right heart: diagnosis, management, and
prognostic indexes in 38 consecutive patients. Circulation 1999;99:2779e83.
2. Ferrari E, Benhamou M, Berthier F, et al. Mobile thrombi of the right heart in pulmonary embolism: Delayed
disappearance after thrombolytic therapy. Chest 2005;121:1051-3.
3. Torbiki A, Galie N, Covezzoli A et al. Right heart thrombi in pulmonary embolism: results from the international
cooperative pulmonary embolism registry. J Am Coll Cardiol 2003;41:2245e51.
4. Casazza F, Bongarzoni A, Centonze F et al: Prevalence and prognostic significance of right-sided cardiac mobile
thrombi in acute massive pulmonary embolism. Am J Cardiol 1997, 79:1433-1435.
5. de Vrey, Bax JJ, Poldermans D et al. Mobile right heart thrombus and massive pulmonary embolism. Eur J
Echocardiogr. 2007 Jun;8(3):229-31. Epub 2006 May 23.
6. European Working Group on Echocardiography, “The European Cooperative Study on the clinical significance of
right heart thrombi,” European Heart Journal, vol. 10, pp. 1046–1059, 1989.
7.Janz RF, Kubert BR, Pate EF et al
Effect of shape on pressure volume relationships of ellipsoidal shells.
Am J Physiol. 1980; 238: H917–H926.
8. Konstantinides S., Geibel A., Heusel G et al
Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism.
N Engl J Med. 2002;347:1143-50.
9. Calvin JE.
Pressure segment length analysis of right ventricular function: influence of loading conditions.
Am J Physiol. 1991; 260: H1087–H1097
11. Onwuanyi AE, Brown RJ, Vahedi M, et al. Eustachian valve thrombus: Critical factor in outcome of venous
thromboembolism. Echocardiography 2003;20:71-3.
11. Thompson CA, TN Skelton. Thromboembolism in the right side of the heart. South Med J 1999;92:826-30.
12. Rose PS, Punjabi NM, Pearse DB: Treatment of right heart thromboemboli. Chest 2002, 121:806-814.
13. Cameron J, Pohlner PG, Stafford EG et al. Right heart thrombus: recognition, diagnosis and management. J Am
Coll Cardiol. 1985 May;5(5):1239-43.
14. G. Pierre-Justin and L. A. Pierard, “Management of mobile right heart thrombi: a prospective series,”
International Journal of Cardiology, vol. 99, no. 3, pp. 381–388, 2005.