Right Sided Intracardiac Thrombosis during Veno-Arterial Extracorporeal Membrane Oxygenation: A Case Report and Literature Review

Abstract

Veno-Arterial Extracorporeal Membrane Oxygenation is a common technology of the modern era used as a bridge in severe refractory cardiac and respiratory failure until definitive management is planned. However, early recognition and management of one of the most challenging complications, intracardiac thrombus, continue to remain a conundrum. The incidence of the clinical scenario is very rare. Therefore, due to the lack of literature, there are no guidelines for risk stratification, prevention, or management of intracardiac thrombus. We describe a case of massive pulmonary embolism, who developed a sudden right sided intra-cardiac thrombosis while being optimally anticoagulated on VA ECMO. We also review the literature to describe the pathophysiology, risk stratification, prevention, and management of this rare entity.

Weaning-Related Shock in Patients With ECMO: Incidence, Mortality, and Predisposing Factors

“…One hypothesis to explain this is pre-existing pulmonary hypertension in many of the patients; another hypothesis would be pulmonary embolism. Cases of pulmonary embolism have been reported under ECMO 22 or after ECMO explantation. 23 Their diagnosis is not systematic because patients can be asymptomatic.…”

Anticoagulation in Patients with Heart Failure and Sinus Rhythm

“…Although no epidemiological data on intracardiac thrombosis exist for heart failure, intracardiac thrombosis is relatively common in clinical practice and is frequently reported in case reports, especially in patients with significantly decreased LVEF. [38][39][40] Intracardiac thrombus may exist in the left cardiac system, right cardiac system, or both. Although a thrombus located in the left cardiac system is prone to causing systemic embolism, a thrombus located in the right cardiac system is prone to inducing pulmonary embolism.…”

Strategies for Left Ventricular Decompression During Venoarterial Extracorporeal Membrane Oxygenation - A Narrative Review

“…Bhat et al 40 described a case report of a patient who developed a new right heart thrombus during VA-ECMO support after a pulmonary embolectomy. Alhussein et al 41 presented a case series of 3 patients who developed intracardiac thrombosis during VA-ECMO, either in the left or right ventricle and the pulmonary circulation.…”