Large embolus in transit – An unresolved therapeutic dilemma (case report and review of literature)

Agarwal, Vratika; Nalluri, Nikhil; Shariff, Masood A.; Akhtar, Muhammad Salman; Olkovsky, Yefim; Kitsis, Paul; Nabagiez, John P.

doi:10.1016/j.hrtlng.2013.08.005

Cited by 16 publications

(22 citation statements)

References 17 publications

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“…Early surgical treatment in patients with pulmonary embolism and thrombus-in-transit (4)(5)(6). Currently, there is not enough evidence about the best treatment option, and recommendations are based on conclusions obtained from case series.…”

Section: Original Articlementioning

confidence: 99%

“…Therefore, TTE is an important tool to its early recognition (1,5,10). In case of doubt, it would be necessary to perform a transesophageal echocardiogram, which is also useful to detect thrombi in the PA and the coexistence of PFO (1).…”

Section: Diagnosismentioning

confidence: 99%

“…Presence of PFO should be taken into consideration as it is a source of paradoxical embolus (emboli originated within the venous system, which pass through a PFO and enter the systemic circulation) and can be a site for the clot to lodge. Some authors favor surgical removal of these thrombi with simultaneous pulmonary embolectomy, due to the impending risk for dislodgement which may either lead to massive PE or paradoxical systemic embolism (5). Despite its prognostic importance, current guidelines do not propose that echocardiography is performed routinely in all patients with acute PE, or in all patients with a non-lowrisk PESI assessment.…”

Section: Diagnosismentioning

confidence: 99%

“…For example, there may be a progressive increase in HR, a decrease in systolic BP (which remains >90 mmHg), an increase in jugular venous pressure, worsening gas exchange, signs of shock (e.g., cold sweaty skin, reduced urine output, confusion), progressive right heart dysfunction on echocardiography, or an increase in cardiac biomarkers (12). However, thrombolytic therapy is not warranted in most cases in abscense of hypotension (5,(12)(13)(14). Few studies, only case series and retrospective studies, have compared thrombolysis with surgical therapy in acute PE and recommended to consider surgical pulmonary embolectomy in case of hypotension and contraindication for thrombolysis or life-threatening situations like failure of thrombolysis, RV failure, cardiogenic shock and TT (3,12,15,16).…”

Section: Treatmentmentioning

confidence: 99%

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Early surgical treatment in patients with pulmonary embolism and thrombus-in-transit

Galeano‐Valle

Demelo‐Rodríguez

García-Fernández-Bravo

et al. 2018

J. Thorac. Dis.

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Background: Floating right heart thrombi (RHT) are in transit from the legs to the pulmonary arteries and thus are a severe form of venous thromboembolism (VTE), with a high early mortality rate without treatment. There is a lack of evidence-based recommendations for its management. The objective of this study is to describe our experience in the surgical management of thrombus-in-transit and pulmonary embolism (PE) in a tertiary hospital. Methods: We recruited four patients with thrombus-in-transit and PE treated with early surgical embolectomy and anticoagulation. Epidemiologic, laboratory, imaging and clinical data of the thromboembolic episode and the subsequent course were collected. Results: The sample included 3 males and 1 female, with a mean age of 49.7. The most frequent initial symptoms were dyspnea, syncope, chest pain and signs of deep vein thrombosis (DVT). Transthoracic echocardiogram (TTE) found the thrombus-in-transit in all the cases. The inicial treatment was unfractionated heparin (UFH) and urgent right atriectomy and manual removal of the thrombi. Three patients needed perioperative infusion of vasopressor drugs. All patients had right heart dysfunction at the time of diagnosis. The mean scoring in the Pulmonary Embolism Severity Index (PESI) was 90. All patients survived after 30 days of follow-up. Conclusions: Early surgical embolectomy of thrombus-in-transit is an effective option of management in selected patients, although the current evidence to support this approach is not definitive.

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Section: Original Articlementioning

confidence: 99%

Section: Diagnosismentioning

confidence: 99%

Section: Diagnosismentioning

confidence: 99%

Section: Treatmentmentioning

confidence: 99%

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Early surgical treatment in patients with pulmonary embolism and thrombus-in-transit

Galeano‐Valle

Demelo‐Rodríguez

García-Fernández-Bravo

et al. 2018

J. Thorac. Dis.

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“…Right heart thrombus is a potentially threatening condition, with a described mortality up to 40% when it's related to massive pulmonary embolism [1]. In some cases, these thrombi are "floating" inside the right atrium, with a significant increase of the embolization risk and, therefore, require an emergent therapeutic decision.…”

Section: Introductionmentioning

confidence: 99%

Surgical Treatment for Floating Right Heart Thrombus in High Risk Patients

Palacios

Hycka

Martín

et al. 2017

ICFJ

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<p>Right heart floating thrombus or “embolus in transit” can be a very dangerous condition, usually associated to pulmonary thromboembolism. Even though many treatment options have been considered, nowadays, the recommended approach remains unclear. Surgical embolectomy has been used as an option, usually less preferred than thrombolysis or percutaneous approach, but it can be a safe and effective procedure in patients with high risk of embolization.</p>

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