Pulmonary Embolism and Intracardiac Type A Thrombus with an Unexpected Outcome

Abstract

Detection of right heart thrombi (RHT) in the context of pulmonary thromboembolism (PE) is uncommon (4–18%) and increases the risk of mortality beyond the presence of PE alone. Type A thrombi are serpiginous and highly mobile and are thought to be originated from large veins and captured in-transit within the right heart. Optimal management of RHT is still uncertain. A 79-year-old woman, with a history of recent total hysterectomy with adnexectomy and a Wells procedure, presented to the emergency department following an episode of syncope. Computed tomography revealed bilateral PE and the presence of a right atrial thrombus. Transthoracic echocardiography demonstrated a free-floating type A thrombus in the right atrium, protruding into the right ventricle, and signs of pulmonary hypertension and right ventricle dysfunction. Considering the recent surgery and clinical stability, treatment with heparin alone was decided. Subsequent clinical improvement was observed and echocardiographic follow-up revealed complete thrombus dissolution and complete recovery of right ventricle function. Most authors recommend treatment of PE with RHT with thrombolysis or embolectomy followed by anticoagulation, although evidence is scarce. Individual risk of hemorrhage and operatory-related mortality should be taken into account when defining the treatment strategy especially when benefit is not firmly established.

Thrombus in Transit: Extract or Dissolve?

“…This thrombus is described as "firmly attached" to the heart chamber wall and appears "in an ovoid shape" [5]. Type C thrombi are uncommon; they are described to have a high degree of mobility and share the characteristics of type A as well as type B right heart thrombi [5,6]. Our patient's TTE showed a TIT across the tricuspid valve with moderate RV dilation ( Figures 1A, 1B).…”

Giant isolated intracardiac thrombus presenting as acute heart failure secondary to right ventricular outflow tract obstruction in a patient with renal carcinoma

“…It is also worthy of note that, for patients with no evidence of a concomitant acute cardiovascular event (e.g. myocardial infarction, pulmonary embolism), to date there are no specific guidelines for the management of intracardiac thrombi, and the relative efficacy of anticoagulation, thrombolysis or other approaches is still unclear [ 10 ]. Lastly, while the negativity of CT angiography makes the hypothesis of concomitant pulmonary embolism unlikely, this possibility cannot be completely excluded.…”

Controversial Fibrinolytic Therapy for Submassive Pulmonary Embolism Related to Right Heart Thrombus

“…2 Pacientes com EP podem ser divididos em três grupos de acordo com seu risco de morte ou complicação maior. 3 • EP maciça: caracterizada por hipotensão sistêmica (i.e., pressão arterial sistólica < 90 mmHg ou queda na pressão arterial sistólica de no mínimo 40 mmHg durante pelo menos 15 min não causada por arritmia) ou choque cardiogênico (manifestado pela evidência de hipoperfusão tecidual e hipóxia). 1 • EP não maciça: o diagnóstico é estabelecido pela ausência de hipotensão sistêmica e choque cardiogênico.…”

“…• EP submaciça: no grupo EP não-maciça, EPS inclui pacientes com disfunção de VD (ou hipocinesia) confirmado por ecocardiografia ou pacientes com elevação de troponina. 1,3 Apesar de ser caracterizada por normotensão, a EPS também é uma das principais causas de morte precoce, sendo o seu prognóstico diferente do de pessoas com EP não-maciça e função VD normal. 1 Em relação à EP maciça, o tratamento com agentes fibrinolíticos encontra-se bem estabelecido em diferentes diretrizes; 3,4 porém, a terapia trombolítica para pacientes com risco intermediário (ou seja, submaciça) ainda é controversa.…”

“…7 O trombo, neste caso em estudo, era morfologicamente serpiginoso e muito móvel, sendo classificado como trombo tipo A. 7 Em pacientes estáveis, a anticoagulação pode ser proposta como um tratamento isolado, principalmente quando existe alto risco de hemorragia. 7 A paciente descrita neste relato de caso apresentava EPS, associada a TMCCD móvel com possível evolução para EP maciça após a trombólise.…”