Thrombolysis for Right Atrial Thrombus-in-Transit in a Patient With Massive Pulmonary Embolism

Abstract

Right atrial thrombus is a rare entity frequently encountered in patients with pulmonary embolism. Although the existing guidelines do not offer a clear statement for the management of right atrial thrombus and pulmonary embolism, this condition is associated with worse outcomes. We present a case of a 79-year-old patient presenting with signs suggestive of massive pulmonary embolism who was found to have a right atrial thrombus on transthoracic echocardiogram and was successfully treated with systemic thrombolysis. Despite the lack of data from randomized studies, right atrial thombi in transit should be considered a severe form of thromboembolic disease often requiring aggressive treatment, particularly in patients with severe right ventricular dysfunction.

Ultrasound-assisted lysis using recombinant tissue plasminogen activator and the EKOS EkoSonic endovascular system for treating right atrial thrombus and massive pulmonary embolism: A case study

“…The presence of RA thrombus in the setting of PE is rare and is associated with worse outcome. 17 Embolization of a large RA thrombus could lead to significant hemodynamic compromise. 17 RA thrombus originates generally from DVT or forms in situ.…”

“…17 Embolization of a large RA thrombus could lead to significant hemodynamic compromise. 17 RA thrombus originates generally from DVT or forms in situ. Highly mobile thrombus is the result of embolization, whereas in situ thrombus tends to be nonmobile and adherent to the walls of the RA or the tricuspid valve or foreign objects such as pacemaker wires.…”

Transit Thrombus in a Patent Foramen Ovale — Time Is Running Out: a Case Report

“…In a thrombus as big as reported here, anticoagulation therapy bears a high risk of either fragmentation or complete embolization causing a stroke or peripheral emboli [4].…”

“…A high right atrial pressure may be due to recurrent embolism causing pulmonary hypertension. This may lead to a reopening of a foramen ovale and paradoxical embolism causing strokes or acute limb ischemia [4].…”

“…In the case of a thrombus-in-transit, a treatment plan needs to be determined on a case-by-case basis. Therapeutic options were anticoagulation therapy with heparin and lifelong warfarin, thrombolysis, or surgical embolectomy [4]. Although surgical thromboembolectomies are associated with fewer complications of recurrent embolic events, there is a risk of intra-and postoperative mortality and morbidity.…”