Right Atrial Thrombosis and Pulmonary Embolism: A Narrative Review

Abstract

Prompt diagnosis of pulmonary embolism (PE) remains challenging, which often results in a delayed or inappropriate treatment of this life-threatening condition. Mobile thrombus in the right cardiac chambers is a neglected cause of PE. It poses an immediate risk to life and is associated with an unfavorable outcome and high mortality. Thrombus residing in the right atrial appendage (RAA) is an underestimated cause of PE, especially in patients with atrial fibrillation. This article reviews achievements and challenges of detection and management of the right atrial thrombus with emphasis on RAA thrombus. The capabilities of transthoracic and transesophageal echocardiography and advantages of three-dimensional and two-dimensional echocardiography are reviewed. Strengths of cardiac magnetic resonance imaging (CMR), computed tomography, and cardiac ventriculography are summarized. We suggest that a targeted search for RAA thrombus is necessary in high-risk patients with PE and atrial fibrillation using transesophageal echocardiography and/or CMR when available independently on the duration of the disease. High-risk patients may also benefit from transthoracic echocardiography with right parasternal approach. The examination of high-risk patients should involve compression ultrasonography of lower extremity veins along with the above-mentioned technologies. Algorithms for RAA thrombus risk assessment and protocols aimed at identification of patients with RAA thrombosis, who will potentially benefit from treatment, are warranted. The development of treatment protocols specific for the diverse populations of patients with right cardiac thrombosis is important.

Case report: A rare case of recurrent right atrial mass dramatically disappeared after anticoagulation

“…Based on the previous studies, our patient was hemodynamically stable and improved significantly with anticoagulant therapy, avoiding the trauma of surgery. There are three types of right heart thrombus ( Table 1 ) ( 1 , 2 ). According to relevant guidelines and studies if thrombolytic therapy is contraindicated or ineffective in hemodynamically unstable patients, surgical thrombectomy is recommended.…”

“…The detection rate of right heart thrombosis in patients with acute pulmonary embolism is 4–18%, which can occur in the right atrium, tricuspid valve, right ventricle, patent foramen ovale, and other sites ( 1 ). Echocardiography is the main diagnostic method for right heart thrombosis, but it still needs to be differentiated from other diseases such as myxoma.…”

Atrial thrombosis: Not only left, think also about right!

“…Courtesy of our center Summarizing, TEE is the preferred methodic for RA/RAA thrombi detection, with a sensitivity varying from 0.92 to 1.00 and a specificity varying from 0.98 to 1.00. 20 In the authors'view it should be performed before cardioversion to rule out a RA/RAA thrombus. In the context of pulmonary embolism, a large RA thrombus or a thrombus straddling the PFO are usually seen routinely with TTE; however, we suggest considering TEE when the TTE window is poor and no deep vein thrombosis is detected, to look for a RAA thrombus secondary to AF or a clot-in-transit from a undetected vein thrombosis.…”

“…Summarizing, TEE is the preferred methodic for RA/RAA thrombi detection, with a sensitivity varying from 0.92 to 1.00 and a specificity varying from 0.98 to 1.00 20 . In the authors'view it should be performed before cardioversion to rule out a RA/RAA thrombus.…”

Editorial: Case reports in thrombosis: 2022

“…Case report: A rare case of recurrent right atrial mass dramatically disappeared after anticoagulation, by Wang et al The presence of right heart thrombosis in patients with pulmonary embolism is very rare, albeit associated with a high mortality ( 6 ). Although echocardiography is often used, cardiac MRI is the imaging tool of choice to ascertain whether a right atrial mass is a myxoma or a thrombus.…”