Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry

Pulmonary Embolism and Right Heart Thrombi: A Single-Center Experience

Background: The right heart thrombus (RHT) embolizes from deep venous thrombi and sits in the right atrium or the right ventricle. We aimed to determine the occurrence and prognosis of the RHT in patients with pulmonary embolism. Methods: We reviewed the cohort data of 622 patients with acute pulmonary embolism obtained from the registry of Tehran Heart Center. Demographic, physiological, clinical, and echocardiographic data, as well as clinical outcomes, were compared between patients with and without the RHT. Results: The study population comprised 622 patients, including 329 men (52.8%). The mean age of the patients was 60.2±17.0 years. Thirty patients (4.8%) had echocardiographically proven RHT. Baseline demographic and clinical characteristics were not different between the 2 groups. Right ventricular dysfunction was more prevalent in the RHT (+) group, and more patients in this group were treated with thrombolysis (P=0.013 and P<0.001, respectively). Overall, 3 out of 21 patients (14.2%) in the RHT (+) group vs 29 out of 306 patients (9.4%) in the RHT (-) group died at 1 month (P=0.445) and 5 out of 21 patients (23.8%) in the RHT (+) group vs 56 out of 307 patients (18.2%) in the RHT (-) group died at 1 year (P=0.562). Conclusion: The RHT is an influential complication in patients with pulmonary emboli, and it seems to increase the mortality rate of patients with acute pulmonary embolism.

[The case of an octogenarian who died of acute myocardial infarction complicated with acute pulmonary embolism from a right ventricular thrombus]

An 86-year-old female on dialysis experienced a decrease in blood pressure and worsening of her respiratory condition during dialysis, for which she visited our emergency unit. She was admitted to our Department of Cardiology with a diagnosis of acute myocardial infarction complicated with heart failure because of anterior wall of left ventricular dysfunction, positive troponin T levels and negative T wave on a precordial lead electrocardiogram. On the same day, she underwent coronary angiography and stenting at left anterior descending artery #7 with 99% stenosis. She also showed an elevated D-dimer level on admission, and contrast-enhanced computed tomography (CT) was performed the day after admission, considering the likelihood of respiratory failure due to pulmonary thromboembolism. However, the findings were negative. On the 4th day of hospitalization, she showed marked hypoxemia. Her D-dimer level was further elevated, and when she underwent enhanced CT again, there was no evidence of deep vein thrombosis, but thrombus in the pulmonary artery and apex of right ventricle was noted. She was therefore diagnosed with acute pulmonary embolism due to thrombosis from the right ventricle rather than from a deep vein. She rapidly received anticoagulant therapy and non-invasive positive pressure ventilation therapy for respiratory failure, but she entered cardiopulmonary arrest and quickly died. She was suspected to have been complicated with a right ventricular infarction and an acute anterior wall myocardial infarction, resulting in a large thrombus along the apex of the right ventricle. This case of both myocardial infarction and pulmonary embolism is very rare, and we report it here with consideration.

Impending paradoxical embolism: about two cases. 3D echocardiographic imaging and discussion of treatment options

INTRODUCTION

Impending paradoxical embolism (IPDE) is a rare condition where a thrombus straddles the foramen ovale with a high risk of arterial embolism.

CASES REPORT

We report two cases of impending paradoxical embolism, an uncommon condition with a high mortality rate. The first in a young woman with acute right heart failure operated emergently, the second, in an old and frail lady presenting an ischemia of the left arm, treated by anticoagulants. 3 D echocardiography imaging is presented and treatment modality is discussed.

CONCLUSION

Emergent treatment is mandatory for IPDE, a serious disease with a high early mortality. This paper is a reminder of how to deal with such a rare condition.

[Thrombus in all four heart chambers in a 67-year-old female patient with pulmonary artery embolism and open foramen ovale]

A 67-year-old woman presented to the emergency department due to acute dyspnea. Computed tomography of the chest showed a pronounced bilateral pulmonary artery embolism. Echocardiography demonstrated a large floating thrombus in the right atrium and right ventricle, which extended through a persistent foramen ovale via the left atrium into the left ventricle. A thrombectomy was later successfully performed.

Right Atrial Thrombi, the Management Conundrum: 2 Case Reports

Case series

Patients: Male, 62-year-old • Male, 66-year-old

Final Diagnosis: Right atrial floating thrombus • right heart thrombus-in-transit

Symptoms: Shortness of breath

Medication: —

Clinical Procedure: —

Specialty: Cardiology

Multimodal echocardiography in the diagnosis of masses localized to the proximal portions of pulmonary arteries

Proximal pulmonary artery masses are exceedingly rare, and their diagnosis and therapy are important and challenging for clinicians. This study reviews our experience exploring the value of a combination of transthoracic echocardiography and contrast echocardiography for the differential diagnosis of proximal pulmonary artery masses. Between January 2018 and June 2021, 44 patients diagnosed with a mass attached to the major pulmonary artery and straddling the bilateral pulmonary arteries or pulmonary valve on transthoracic echocardiography were referred to this study. Contrast echocardiography was performed in 17 patients. Masses were diagnosed based on their site of attachment, shape, size, mobility, hemodynamic consequences on transthoracic echocardiography, and tissue perfusion on contrast echocardiographic perfusion imaging. Pathological data were collected from medical records and analyzed. The most frequent location of proximal pulmonary artery masses was the major pulmonary artery trunk. Twelve patients underwent complete mass resection, whereas nine patients underwent percutaneous pulmonary artery biopsy puncture and had a pathological diagnosis. Another 24 patients were confirmed with the validation methods. Contrast echocardiography has good sensitivity and specificity for differentiating thrombi from pulmonary artery sarcomas (PAS). The mass types were distributed as follows: thrombi (19, 43%), PAS (15, 34%), metastatic tumors (6, 14%), vegetations (3, 7%), and primary benign lesions (1, 2%). The majority of proximal pulmonary artery masses were thrombi or PAS. A combination of transthoracic echocardiography and contrast echocardiography offers advantages in the early identification of proximal pulmonary masses and provides clinically important information about the characteristics of masses, especially for differentiating thrombi from PAS.

Right heart thrombus-in-transit in a patient with Evans syndrome: A case report

INTRODUCTION

Right heart free-floating thrombus in the absence of structural heart disease or atrial fibrillation is rare. When it travels to the heart into the lung, called thrombus-in-transit, may cause cardiopulmonary collapse and sudden death. The clinical presentation varies from mild respiratory symptoms to sudden death; however, there are few clinical case reports of giant, free-floating thrombus in the right heart in an asymptomatic patient, and the optimal management options have not been established.

PATIENT CONCERNS

A 36-year-old Asian woman presented to the emergency department with complaints of worsening swelling of the left lower extremity over 12 hours.

DIAGNOSIS

Left leg deep vein thrombosis accompanied by an asymptomatic giant right atrial thrombus and pulmonary embolism with a rare autoimmune disease of Evans syndrome.

INTERVENTIONS

Emergent surgical thrombectomy under cardiopulmonary bypass for right atrial thrombus.

OUTCOMES

The postoperative course was uneventful, and she was discharged on the eighth postoperative day with normal heart function and mild tricuspid regurgitation.

CONCLUSION

An additional diagnostic workup in cases of deep vein thrombosis is necessary for the rapid diagnosis of right heart thrombus and pulmonary embolism without delay. This case report illustrates that early recognition of venous thromboembolism and emergent thrombectomy of right heart thrombus-in-transit is crucial to prevent mortality.

Submassive pulmonary embolism with a right heart thrombus

A 49-year-old woman presented to the hospital with shortness of breath 2 weeks after a left total hip replacement. She was found to have a submassive pulmonary embolism (PE), with her case complicated by the detection of a large mobile clot in transit extending through a patent foramen ovale between the right and left atria. The presence of this free-floating right heart thrombus (FFRHT) increases her risks of stroke and mortality, yet the optimal approach to her treatment was unclear. Ultimately, intravenous tissue plasminogen activator was administered with resolution of the clot. Treatment was complicated by haemodynamically insignificant bleeding at the site of recent surgery. Herein, we further discuss the implications and treatment options for patients with an FFRHT in the setting of an acute PE.

Suction thrombectomy of a massive, hypermobile (type C) right atrial thrombus: a case report

Background

Right atrial thrombus (RAT) may be managed according to morphology and aetiology, i.e. Type A thrombi (‘clot-in-transit’, hypermobile) are managed with thrombolytics and surgical embolectomy due to high risk of embolization; Type B thrombi (broad-based, globular) may be managed medically as they will very likely maintain a benign course. Experience with management of a Type C thrombus (hypermobile but also broad-based) has not been explicitly described in the literature.

Case summary

A 25-year-old man with history of leukaemia with prior right subclavian vein chemoport is found to have massive RAT. Multimodal imaging shows a hypermobile mass attached to the right atrial lateral wall inferior to superior vena cava and prolapsing into right ventricle in diastole. Given the thrombus morphology and likely propagation from subclavian port, risk of catastrophic embolization was deemed high and as such, intervention was indicated. Systemic anticoagulation was considered but deferred due to theoretical risk of dissolving the thrombus stalk leading to embolization. Surgical thrombectomy was offered but the patient declined. Due to evidence for success in RAT, the AngioVac System: Generation 3 (Angiodynamics, Inc., Latham, NY, USA) was chosen for intervention. The RAT was successfully removed without any complication.

Discussion

AngioVac suction thrombectomy is a safe alternative option for removal of a Type C, massive, hypermobile RAT.

Paradoxical Cerebral Embolization Caused by Thrombus-In-Transit via a Patent Foramen Ovale in a Patient with Symptomatic Pulmonary Embolism: A Case Report

Objective

Acute pulmonary embolism (PE) is a life-threatening cardiovascular event associated with high mortality and morbidity. The presence of a patent foramen ovale (PFO) in patients with acute PE represents a risk factor for mortality. Furthermore, a thrombus-in-transit via a PFO with impending paradoxical embolism carries a high mortality rate.

Case Presentation

An adult patient with ischemic stroke caused by paradoxical embolism following PE underwent mechanical thrombectomy and achieved successful recanalization. Initial CT pulmonary angiography (CTPA) showed not only pulmonary thromboemboli but also bilateral atrial thromboemboli. During hospitalization, transesophageal echocardiography (TEE) revealed the PFO with a right-to-left shunt. Two months after rehabilitation undergone by the patient, PE completely disappeared and PFO closure was conducted to reduce the recurrence risk of ischemic stroke.

Conclusion

Not only cardiologists but also interventional neurologists should understand that CTPA can demonstrate the thrombus-in-transit through the PFO and provides a reliable prediction of the sudden onset of ischemic stroke in patients with symptomatic PE. When identified, considering a case-by-case treatment approach by multidisciplinary teams is essential for preventing further life-threatening paradoxical embolization.

Predictive role of the modified Glasgow prognostic score for in-hospital mortality in stable acute pulmonary embolism

BACKGROUND AND IMPORTANCE

The modified Glasgow prognostic score (mGPS) has been reported to have a prognostic value in various patient populations. However, the prognostic significance of mGPS has not been studied inacute pulmonary embolism (APE).

OBJECTIVE

This study aimed to investigate the predictive value of mGPS on in-hospital mortality in patients with hemodynamically stableAPE.

METHODS

We retrospectively included 258 hemodynamically stableAPE patients. Clinical, echocardiographic, and laboratory data recorded on admission. The mGPS scored as 0, 1, or 2 based on the C-reactive protein (CRP) and albumin levels.

RESULTS

A total of 258hemodynamically stableAPE patients were included, and 28 (10.9%) died during the hospital stay. Compared with survivors, non-survivors were older, had higher N-terminal pro-B-type natriuretic peptide, CRP, creatinine, high-sensitive cardiac troponin T (hs-cTnT), and mGPS levels, and had higher pulmonary embolism severity index (PESI) at study entry. In the multivariate logistic regression analysis, NT-proBNP>2350pg/mL (OR: 2.180, 95% CI 1.102-5.213, p<0.001), hs-cTnT>21pg/mL (OR: 1.426, 95% CI 0.951-3.751, p=0.001), CRP>3.1mg/dL (OR: 1.567, 95% CI 1.072-4.429, p=0.001), PESI>139 (OR: 2.745, 95% CI 0.869-6.369, p=0.001), systolic blood pressure<100mmHg (OR: 3.465, 95% CI 0.867-8.934, p<0.001), mGPS=1 (OR: 2.120, 95% CI 1.089-3.754, p=0.011), and mGPS=2 (OR: 3.350, 95% CI 1.457-5.367, p<0.001) were independently associated with in-hospital mortality.

CONCLUSION

This study demonstrates the mGPS, which is a new and easily measurable marker, is a useful predictor in-hospital mortality in hemodynamically stableAPE.

Clinical Significance and Prognosis of Right Heart Thrombi Associated With Acute Pulmonary Thromboembolism - Results of a Multicenter Registry of Thrombolysis in Japan

BACKGROUND

Thrombolytic therapy is standard treatment in acute pulmonary thromboembolism (PTE) with hemodynamic instability. Although right heart thrombi (RHT) appear to increase mortality in acute PTE, large-scale studies of acute PTE with RHT are scarce.

METHODS AND RESULTS

Patient data (from August 2005 to May 2014) obtained from post-marketing surveillance of thrombolytic therapy using a tissue-type plasminogen activator were analyzed retrospectively. Of the 2,698 confirmed cases of acute PTE who underwent echocardiographic assessment, 166 (6.2%) were diagnosed with RHT. PTE patients with RHT, compared with those without RHT, had higher rates of mortality (20.2% vs. 10.4%, P<0.001), hemodynamic instability (53.0% vs. 37.7%, P<0.001), and PTE recurrence (6.6% vs. 2.3%, P=0.003). When considering PTE-related hemodynamic severity (cardiopulmonary arrest/collapse, massive, submassive, and non-massive), mortality was significantly higher in patients with RHT in the massive (19.8% vs. 7.7%, P=0.002) and submassive (8.0% vs. 2.8%, P=0.018) groups, whereas no significant differences was found between those with and without RHT in the cardiopulmonary arrest/collapse (51.7% vs. 52.1%, P=0.960) and non-massive (1.6% vs. 0%, P=0.596) groups.

CONCLUSIONS

PTE patients with RHT had higher mortality, severity, and PTE recurrence rates. RHT was particularly associated with worse outcomes in patients with massive or submassive PTE.

Emergent mechanical thrombectomy for right atrial clot and massive pulmonary embolism using flowtriever

This case demonstrated a feasible alternative to treat "clot in transit" associated with pulmonary embolism using FlowTriever Inari device. The pre-existing approved AngioVac device requires extracorporeal circulation support and more invasiveness. FlowTriever permits mechanical thrombectomy with versatile approach without additional extracorporeal perfusion setting. Additional studies are required to reach a definitive conclusion.

Evaluating the Right Ventricle in Acute and Chronic Pulmonary Embolism: Current and Future Considerations

The right ventricle (RV), due to its morphologic and physiologic differences, is susceptible to sudden increase in RV afterload, as noted in patients with acute pulmonary embolism (PE). Functional impairment of RV function is a stronger presage of adverse outcomes in acute PE than the location or burden of emboli. While current iterations of most clinical prognostic scores do not incorporate RV dysfunction, advancements in imaging have enabled more granular and accurate assessment of RV dysfunction in acute PE. RV enlargement and dysfunction on imaging is noted only in a subset of patients with acute PE and is dependent on underlying cardiopulmonary reserve and clot burden. Specific signs like McConnell's and "60/60" sign are noted in less than 20% of patients with acute PE. About 2% of patients with acute PE develop chronic thromboembolic pulmonary hypertension, characterized by continued deterioration in RV function in a subset of patients with a continuum of RV function from preserved to overt right heart failure. Advances in molecular and other imaging will help better characterize RV dysfunction in this population and evaluate the response to therapies.

Risk Stratification in Acute Pulmonary Embolism: The Latest Algorithms

Pulmonary embolism (PE) is a common clinical entity, which most clinicians will encounter. Appropriate risk stratification of patients is key to identify those who may benefit from reperfusion therapy. The first step in risk assessment should be the identification of hemodynamic instability and, if present, urgent patient consideration for systemic thrombolytics. In the absence of shock, there is a plethora of imaging studies, biochemical markers, and clinical scores that can be used to further assess the patients' short-term mortality risk. Integrated prediction models incorporate more information toward an individualized and precise mortality prediction. Additionally, bleeding risk scores should be utilized prior to initiation of anticoagulation and/or reperfusion therapy administration. Here, we review the latest algorithms for a comprehensive risk stratification of the patient with acute PE.

Thrombolysis of a massive intracardiac thrombus during resuscitation: documentation by transoesophageal echocardiography

Acute pulmonary embolism is a frequent potentially reversible cause of sudden cardiac arrest. The early diagnosis is challenging but essential for further treatment. New therapeutic options in resuscitation, such as extracorporeal resuscitation, are leading to frequent transports of patients to emergency rooms with ongoing resuscitation. A transoesophageal echo performed during resuscitation can give hints for reversible causes for the cardiac arrest. We present a case of a 40-year-old female patient who was transferred to our department with ongoing resuscitation and received a transoesophageal echo immediately on arrival. The examination showed a massive intracardiac thrombus. The subsequent thrombolysis and following resuscitation were observed and documented via transoesophageal echo.

Incidence of catheter-associated right atrial thrombus detected by transthoracic echocardiogram

INTRODUCTION

The development of right atrial (RA) thrombus (RAT) is a known complication of central venous catheter insertion (CVC). Deeper insertion of CVC within the RA may increase the risk for RAT development versus those placed at the superior vena cava (SVC)-RA junction. We sought to evaluate the incidence of catheter-associated RAT as detected by transthoracic echocardiograms (TTEs), characterize thrombi though multimodal imaging, and evaluate thrombi management with follow-up imaging.

METHODS

A retrospective analysis was conducted of consecutive TTEs from our institution between October 1, 2018, and January 1, 2020, in which a venous catheter was visualized in the RA. Studies were reviewed in detail to determine the presence of suspected RAT. Demographic data, comorbidities, laboratory values, characteristics of the catheter and the thrombus, subsequent imaging and management, and outcomes were collected.

RESULTS

A total of 364 TTEs were performed in 290 patients with a venous catheter visualized in the RA. Of these 290 patients, 15 had an imaging suspicion for RAT yielding an incidence of 5.2%. Management strategies included anticoagulation in 13 (86.7%) patients and catheter removal in 11 (73.3%) patients. At eight months of follow-up, 11 (73.3%) patients had resolution of RAT based on subsequent imaging.

CONCLUSION

In patients with deeply placed CVC catheters, the incidental detection of RAT by TTE was not trivial. Anticoagulation and catheter removal and replacement, if deemed safe, were effective methods of thrombus management. RAT as a complication of CVCs must be accounted for when addressing factors that influence depth of CVC insertion.

Endovascular Removal of Thrombus and Right Heart Masses Using the AngioVac System: Results of 234 Patients from the Prospective, Multicenter Registry of AngioVac Procedures in Detail (RAPID)

PURPOSE

To assess device and procedural safety and technical success associated with the use of the AngioVac System to remove vascular thrombi and cardiac masses.

MATERIALS AND METHODS

The Registry of AngioVac Procedures in Detail (RAPID) study prospectively collected data for 234 patients receiving treatment with AngioVac at 21 sites between March 2016 and August 2019: 84 (35.9%) with caval thromboemboli (CTEs), 113 (48.3%) with right heart masses (RHMs), 20 (8.5%) with catheter-related thrombi (CRTs), and 4 (1.7%) with pulmonary emboli (PEs). Thirteen patients had a combination of procedures during the same admission.

RESULTS

Using the AngioVac system, 70%-100% thrombus or mass removal was achieved in 73.6% of patients with CTEs, 58.5% of patients with RHMs, 60% of patients with CRTs, and 57.1% of patients with PEs. Extracorporeal bypass time was < 1 hour for 176 (75.2%) procedures. Estimated blood loss was < 250 mL for 179 procedures (76.5%). Mean hemoglobin decreased from 10.4 g/dL ± 2.9 preoperatively to 9.4 g/dL ± 2.6 postoperatively. Transfusions were administered in 59 procedures (25.2%) with 47 transfusions (78.2%) being ≤ 2 U. There were 36 procedure-related complications, including 1 death.

CONCLUSIONS

The RAPID registry data demonstrate that the AngioVac System can be safely and effectively used to remove vascular thrombi and cardiac masses across a broad range of patient populations. The limited use of the device to remove pulmonary emboli in the present series precludes recommending the use of the AngioVac device for this indication.

A Floating Right Atrial and Ventricular Thrombus in a Patient with Syncope

Here, we describe a rare echocardiographic finding of a floating right heart thrombus in an elderly woman who presented with an unexplained syncope. Our case demonstrates the pivotal role of echocardiography in the workup of patients admitted with syncope.

Right Atrial Thrombosis and Pulmonary Embolism: A Narrative Review

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.

“PERT-inent” Management: The Role of the Pulmonary Embolus Response Team in Managing Paradoxical Embolus in Transit

A 52-year-old man presented with palpitations and dyspnea. Extensive bilateral pulmonary emboli (PEs) were identified on computed tomography pulmonary angiogram. Transthoracic echocardiography demonstrated a mobile bi-atrial thrombus straddling the interatrial septum. Consensus decision of a multidisciplinary pulmonary embolus response team was made for emergency thrombectomy of the pulmonary and intra-cardiac clot. Intraoperatively, a patent foramen ovale was identified and repaired. He had an excellent outcome and was discharged home on oral anticoagulation. In this unique case of a bi-atrial thrombus and sub-massive PEs, we demonstrate the utility of dedicated pulmonary embolus response teams in providing rapid and individualized management decisions for complex PE patients.

A Unique Case of Co-Occurrence of Bilateral Pulmonary Artery Embolism and Right Atrium Thrombus

Pulmonary embolism (PE) is considered a major cause of morbidity and mortality in both inpatient and outpatient settings. PE can be presented in different clinical pictures. However, the association between PE and right atrial thrombus is not frequently reported. PE is categorized based on size, location and clinical presentation. Although management changes between different PE sub-types, optimal medical therapy is not well established for coexisting PE with right atrial thrombus. Herein, we present a unique case of a 58-year-old male with bilateral PE and atrial thrombus, with no known underlying risk factors.

Current Controversies in Caring for the Critically Ill Pulmonary Embolism Patient

Emergency physicians must be prepared to rapidly diagnose and resuscitate patients with pulmonary embolism (PE). Certain aspects of PE resuscitation run counter to typical approaches. A specific understanding of the pathophysiology of PE is required to avoid cardiovascular collapse potentially associated with excessive intravenous fluids and positive pressure ventilation. Once PE is diagnosed, rapid risk stratification should be performed and treatment guided by patient risk class. Although anticoagulation remains the mainstay of PE treatment, emergency physicians also must understand the indications and contraindications for thrombolysis and should be aware of new therapies and models of care that may improve outcomes.

Cardiopulmonary resuscitation may cause paradoxical embolism

This paper reports a case of paradoxical embolism of right heart thrombi visualized on transesophageal echocardiography during cardiopulmonary resuscitation (CPR). CPR may cause a right-to-left shunt by producing a sudden increase in right atrial pressure during the compression phase. In cardiac arrest patients with right heart thrombi who have received CPR, systemic embolization can occur owing to paradoxical embolism.

Right Heart Thrombus in Transit Diagnosed With Focused Cardiac Ultrasound in the Emergency Department

The diagnosis of a right heart thrombus (RHTh) in transit associated with pulmonary embolism (PE) is an uncommon phenomenon with a high mortality rate. Timely recognition of RHTh with focused cardiac ultrasound (FOCUS) in cases of suspected PE is necessary for critical decision making in the emergency department (ED). We present a case of RHTh with submassive PE in which the patient underwent successful catheter-directed thrombolysis. This case report illustrates the significance of an emergency physician (EP) implementing FOCUS during the initial ED evaluation to rapidly diagnose RHTh in transit and initiate PE therapy without delay.

Acute Massive Pulmonary Embolism with Direct Visualization of a Free-floating Right Heart Thrombus Successfully Treated with Fibrinolysis: A Case Report

A male patient with a history of immobilization due to motor weakness, was transferred to our emergency department after syncope during physiotherapy, with recorded hypotension. Transthoracic echocardiography showed severe dilatation of the right ventricle (RV), with apex hypercontractility and almost akinetic RV free wall. The above findings, in addition to the unexpected visualization of a large, free-floating, right atrial thrombus, a rare finding associated with high mortality, readily confirmed the clinical suspicion of acute pulmonary embolism (PE) causing circulatory collapse. Intravenous fibrinolysis and vasopressor therapy were successfully administered, and hemodynamic instability was soon alleviated.

Clinical and radiological diagnosis of pulmonary thromboembolism

Pulmonary thromboembolism has poorly specific clinical symptomatology, which increases the diagnostic suspicion, multiplying the number of patients who will need to undergo imaging tests to confirm the diagnosis. In recent years, pulmonary angiography using multidetector scanners (CT angiography) has been the most widely used imaging test due to its availability and accuracy, which exceeds that of lung ventilation-perfusion (V/Q) scintigraphy. However, CT angiography is not without risks and is also expensive. Its use should therefore be restricting without reducing the diagnostic efficacy, given its enormous prognostic importance and implication. We therefore need to base our approach on previously validated strategies that, taking into account the clinical probability and using highly sensitive diagnostic tests such as D-dimer, will enable us to exclude many patients from undergoing this imaging test. In this article, we review the diagnostic techniques and strategies that are applied for diagnosing pulmonary thromboembolism in hemodynamically stable and unstable outpatients, hospitalised patients, patients with a history of venous thromboembolism and pregnant women.

Jugular venous catheter-associated thrombosis and fatal pulmonary embolism: A case report

INTRODUCTION

Central venous catheters related thrombosis (CRT) insertion has been shown to increase the risk of venous thromboembolism, particularly pulmonary embolism (PE). Nevertheless, deaths cased due to PE have been rarely reported.

PATIENT CONCERNS

A central venous catheter was introduced through the right jugular vein during the operation due to severe septic shock from a 57-year-old male patient. Two days after surgery, the hemodynamics was stable. On the 7th day, and low molecular weight heparin calcium (4100 units, once a day) was added for anticoagulation to prevent venous thromboembolism. On the 15th day, during the process of central venous catheter removal, the patient suddenly lost consciousness, suffered cardiac arrest, and received emergency cardiopulmonary resuscitation.

DIAGNOSIS

Jugular venous catheter-associated thrombosis and fatal PE. An acute bedside ultrasound showed a thrombus drifting with the blood stream in the right jugular vein. The lower section of the xiphoid process by echocardiography showed decreased systolic amplitude of the right atrium and right ventricle, widened and fixed inferior vena cava, and no variation with respiration. Para-sternal left ventricular long axis section showed that the right ventricular outflow tract was significantly extended, and the contraction amplitude of the anterior and posterior walls of the left ventricle decreased. Left ventricular short axis section indicated a right ventricle enlargement and ventricular septum deviation of left ventricle, showing "D" sign. Apical 4-chamber view showed that the right ventricular ratio increased and the contractile capacity decreased.

INTERVENTIONS

One and a half million units of urokinase were immediately given trough intravenous drip.

OUTCOMES

Twenty minutes after thrombolysis, the patient's autonomic heart rhythm was recovered, but continued to suffer from hypotension and coma, followed by multiple organ failure, and died 50 hours later.

CONCLUSION

Recent clinical practice guidelines recommend against the routine use of any anticoagulant thromboprophylaxis in patients with central venous catheters, but for patients at particularly high risk for CRT, consideration can be given to using higher doses of anticoagulant as prophylaxis, although there are virtually no data to support this approach.

Point-of-care ultrasound (POCUS) as the keystone investigation in undifferentiated dyspnoea

Dyspnoea is defined as a subjective perception of laboured breathing. It is a common cause of access to the emergency department (ED), it has a high rate of intensive care unit admission and a high mortality. The most common causes of dyspnoea in the adult include pneumonia, heart failure, chronic obstructive pulmonary disease, pulmonary embolism and asthma. Due to the high variety of dyspnoea's causes, the need for a rapid and accurate diagnosis puts the emergency physician in trouble. Moreover, standard tests such as chest radiography, B-type natriuretic peptide and d-dimer require time and may be less useful in patients with respiratory failure who require urgent therapy. Point-of-care ultrasound (POCUS) is rapid, non-invasive, repeatable and a useful tool in evaluating patients with acute and severe dyspnoea. This case report demonstrates the usefulness of POCUS in a patient with undifferentiated respiratory failure presenting to the ED.

A Case Report of Polymerase Chain Reaction-Confirmed COVID-19 in a Patient With Right Ventricular Thrombus and Bilateral Deep Vein Thrombosis

The new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), that causes the highly contagious coronavirus disease 2019 (COVID-19) has led to an unprecedented global health crisis. Infected patients have been shown to trigger a heightened inflammatory response, increasing thrombotic risk. We report the case of a polymerase chain reaction (PCR)-confirmed COVID-19 in a Hispanic male with no past medical history who presented to the ED with upper respiratory tract symptoms including shortness of breath and cough, requiring continuous positive airway pressure (CPAP) therapy. He was found to have a right ventricular thrombus (RVT) and bilateral deep vein thrombosis (DVT) on the day of admission, which were detected on transthoracic echocardiogram and duplex venous ultrasound, respectively. The patient was started on therapeutic enoxaparin sodium, which led to an improvement in oxygenation, and he was eventually downgraded to the medical floors for further management.

Thrombolysis of Postoperative Acute Pulmonary Embolism with a Thrombus in Transit

Right heart thrombus in transit clot (RHTT) associated with a pulmonary thromboembolism (PTE) is a rare but potentially fatal diagnosis. Early diagnosis and immediate intervention are crucial. This report describes the case of a healthy, physically active 32-year-old female who presented 19 days postoperatively, following an anterior cruciate ligament reconstruction and partial lateral meniscectomy with a saddle PE, RHTT, and right ventricular (RV) strain. The patient received half of the standard dose of intravenous tissue plasminogen activator (TPA) in combination with anticoagulation and survived. Case reports of RHTT will inform future studies designed to evaluate whether and when thrombolysis should be administered.

Special Considerations in Pulmonary Embolism: Clot-in-Transit and Incidental Pulmonary Embolism

This article describes 2 relatively rare, but complex situations in pulmonary embolism (PE): clot-in-transit (CIT), incidental PE (IPE). CIT describes a venous thromboembolism that has become lodged in the right heart. CIT is associated with high mortality and presents unique challenges in management. Incidental PE (IPE) describes PE diagnosed on imaging performed for another indication. The treatment is complex because there is often a disconnect between the PE severity on imaging and lack of severity of the clinical presentation. We summarize the available literature and aid clinicians as they manage patients with PE across the clinical severity spectrum.

Cardiac Masses in Echocardiography: A Pragmatic Review

Transthoracic echocardiography is a useful diagnostic technique for the identification of intracardiac and extracardiac masses, which can evaluate morphologic properties of the masses such as their location, attachment, shape, size, mobility, and possible hemodynamic-related implications. Apart from physiological variants and structural normal mimickers, echocardiography can detect principal intracardiac masses such as neoplasms, thrombi, vegetation, and extracardiac masses such as metastatic lesions. Moreover, transesophageal echocardiography can provide further details and provide higher accuracy in case a deeper examination of the mass is needed. This review will focus on the systematic evaluation of intra-/extracardiac masses including epidemiology and morphological and echocardiographic features, providing practical and technical tips to health-care professionals to achieve correct identification of the masses. General data on cardiac masses were extracted via PubMed/MEDLINE search engine from indexed reviews, original studies, and clinical case reports. The echocardiographic features of cardiac masses were reviewed according to the most relevant international cardiology and echocardiography scientific societies' position statements.

Saved by the VAC: Minimally Invasive Removal of a Surely Fatal Right Heart Thrombus in a Patient with Advanced Heart Failure

Intracardiac thrombi are associated with an increased morbidity and mortality due to their unpredictability and embolic potential. Right heart thrombus is infrequently encountered in clinical practice outside the scenario of acute pulmonary embolism with hemodynamic compromise, and even more uncommon is the presence of a massive right heart thrombus. Embolic potential is high, and historically, management has revolved around open surgical removal or systemic thrombolysis. We hereby present a case of a massive right heart thrombus in a high surgical risk patient, which was successfully removed using a percutaneous aspiration device.

Pulmonary hypertension: when the acute event leads to diagnosis. Case report in a patient with Ehlers-Danlos syndrome

Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is a pulmonary vascular pathology caused by the chronic obstruction of the major pulmonary arteries, usually being the consequence of recurrent episodes of pulmonary embolism. Such events are usually unknown; the delay in such a diagnosis can therefore lead to a deterioration of the clinical picture, worsening the overall prognosis.  This is a case of a 55-year-old man who came to the Emergency Room (ER) because of an acute exacerbation of chronic dyspnea, that he experienced for several years, in the absence of an explanatory diagnosis. Acute pulmonary embolism was diagnosed in the setting of the ER, with bedside echography resulting to be crucial to the work up. A multidisciplinary approach allowed proper treatment, management and a favourable outcome.

Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practice from the PERT Consortium

Pulmonary embolism (PE) is a life-threatening condition and a leading cause of morbidity and mortality. There have been many advances in the field of PE in the last few years, requiring a careful assessment of their impact on patient care. However, variations in recommendations by different clinical guidelines, as well as lack of robust clinical trials, make clinical decisions challenging. The Pulmonary Embolism Response Team Consortium is an international association created to advance the diagnosis, treatment, and outcomes of patients with PE. In this consensus practice document, we provide a comprehensive review of the diagnosis, treatment, and follow-up of acute PE, including both clinical data and consensus opinion to provide guidance for clinicians caring for these patients.

Percutaneous Vacuum-Assisted Thrombectomy Using AngioVac Aspiration System

BACKGROUND

Surgical embolectomy and thrombolytic therapy are two common approaches for the treatment of large intra-cardiac or intravascular thrombi to prevent new or worsening pulmonary embolism (PE). Considering high operative mortality with surgical embolectomy and high bleeding risk with thrombolytic therapy, patients who are poor candidates for these treatments may benefit from percutaneous aspiration thrombectomy/Vacuum-assisted thrombectomy (VAT). AngioVac aspiration system was granted 510(k) clearance by the United States Food and Drug Administration (FDA) in April 2009. We present a case series to describe its use and outcomes in evacuating large caval thrombi or intracardiac masses.

METHODS

We did a retrospective analysis of AngioVac catheter based thrombectomy in 16 consecutive patients treated between January 2016 and January 2019 to report case characteristics and in-hospital clinical outcomes.

RESULTS

Sixteen patients (mean age 48) underwent 16 AngioVac procedures over 48 months. Indications included intracardiac mass (68.8%), caval thrombus (56.3%), and catheter associated thrombus (43.8%). 7 (43.8%) patients had concurrent PE. Peri-procedure mortality was 0% and in-hospital mortality was 12.5% at a mean follow-up of 14 days. There were no pulmonary hemorrhages, strokes or myocardial infarctions. 62.5% had a significant drop in hemoglobin, which required a blood transfusion but there was no episode of overt bleeding.

CONCLUSION

The AngioVac aspiration system has been shown to be effective at aspirating large volumes of intravascular and intracardiac thrombus. It is a reasonable alternative to surgical thrombectomy in patients with large central thrombi or masses in-transit who are at risk of complicated PE.

Role of Imaging for Suspected Cardiac Thrombus

PURPOSE OF REVIEW

Cardiac thrombus formation is a frequent complication of a variety of prevalent diseases. Embolism of cardiac thrombus has the potential to result in significant morbidity and mortality from cerebrovascular and peripheral vascular events.

RECENT FINDINGS

Echocardiography is the most commonly used imaging modality for diagnosing intracardiac thrombus. However, technological advances in computed tomography and magnetic resonance imaging have allowed newer noninvasive modalities to evolve into robust tools for the clinical evaluation of patients suspected of disease. Complimentary use of these imaging techniques is crucial in the diagnosis of cardiac thrombus and initiation of anticoagulation therapy.