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

Heart disease in patients with pulmonary embolism

PURPOSE OF REVIEW

Several heart diseases are promoters of left-side cardiac thrombosis and could lead to arterial embolism. The same mechanism may be responsible for right-side cardiac thrombosis and therefore be a direct source of pulmonary embolism.

RECENT FINDINGS

Yasuoka et al. showed a higher incidence of perfusion defects in lung scan in patients with spontaneous echocontrast in the right atrium than in those without it (40% and 7% respectively; P=0.006). We recently assessed the prevalence of heart diseases in 11.236 consecutive patients older than 60 years discharged from Venetian hospitals with a diagnosis of pulmonary embolism. We observed a higher prevalence of all-cause heart diseases (odds ratio 1.26; 95% confidence interval, 1.13-1.40) in patients with a diagnosis of pulmonary embolism alone (secondary or unprovoked) compared with those discharged with a diagnosis of pulmonary embolism associated with deep vein thrombosis, generating the hypothesis that some specific heart diseases in older patients could themselves be a possible source of pulmonary emboli.

SUMMARY

Further prospective studies are required to confirm these findings, which have the potential to open new horizons for the interpretation and management of venous thromboembolic disease.

The first three-dimensional visualization of a thrombus in transit trapped between the leads of a permanent dual-chamber pacemaker: a case report

Introduction

Two-dimensional echocardiography is a useful tool in diagnosing cardiac masses. However, the three-dimensional offline reconstruction technique of transesophageal echocardiography might be superior to two-dimensional transesophageal echocardiography in providing additional information of structural details.

Case presentation

We report the case of a 76-year-old Caucasian man with a permanent dual-chamber pacemaker and a worm-like right-heart thrombus in transit. Two-dimensional transthoracic echocardiography and two-dimensional transesophageal echocardiography showed that it was debatable as to whether "the worm" was originating from the leads. Offline three-dimensional transesophageal echocardiography reconstruction technique proved superior in identifying the cardiac mass as a thrombus trapped between the leads of the pacemaker. The thrombus was successfully dissolved by systemic heparin therapy.

Conclusions

The three-dimensional transesophageal echocardiography is useful and effective in patients with implanted pacemakers or defibrillators when other closely competing imaging modalities are contraindicated, such as magnetic resonance imaging. In patients with pacemakers and trapped thrombus in transit for whom surgical therapy might be a high risk, medical therapy seems to offer a safer and convincing alternative. Whether the management of right-heart thrombi has to be modified due to the presence of pacemaker leads is controversial.

Pulmonary thromboembolic disease. Clinical management of acute and chronic disease

Pulmonary thromboembolism falls between the areas of pulmonology and cardiology, internal medicine and intensive care, radiology and nuclear medicine, and hematology and cardiothoracic surgery. Depending on their clinical background, physicians faced with a patient with a pulmonary thromboembolism may speak different languages and adopt different treatment approaches. Now, however, there is an opportunity to end the Tower of Babel surrounding pulmonary thromboembolism. There is a growing acknowledgement that the key clinical problems in both acute pulmonary embolism and chronic thromboembolic pulmonary hypertension are linked to right ventricular pressure overload and right ventricular failure. As a result, cardiologists and cardiac intensive care specialists are taking an increasing interest in understanding and combating these conditions. The European Society of Cardiology was the first to elaborate comprehensive clinical practice guidelines for pulmonary thromboembolism and chronic thromboembolic pulmonary hypertension. The task forces involved in producing these guidelines included radiologists, pulmonologists, hematologists, intensive care physicians and surgeons, which ensured that the final document was universally acceptable. The aim of this article was to provide an overview of the epidemiology, risk factors, diagnosis, treatment, prognosis and prevention of acute pulmonary thromboembolism and chronic thromboembolic pulmonary hypertension, while taking into account European Society of Cardiology guidelines and incorporating new evidence where necessary.

An embolus in the right atrium caught in the Chiari network and resistant to thrombolysis

This case report describes a patient with thromboemboli trapped in the Chiari network within the right side of the heart and resistant to thrombolysis. The right atrial masses were completely removed under cardiopulmonary bypass. Histological evaluation confirmed a mixed thromboemboli, with thrombus structures showing signs of organisation and surrounded by a fibrous capsule. The plasma level of the plasminogen activator inhibitor type-1 (PAI-1) was 50% higher than the normal upper limit. In this presented case, the Chiari network displayed a protective function but the expansion and organisation of the thromboembolus found there made it resistant to lytic treatment. Another important factor that could have influenced the resistance to thrombolysis was the high level of PAI-1.

Mortality risk assessment and the role of thrombolysis in pulmonary embolism

Acute venous thromboembolism remains a frequent disease, with an incidence ranging between 23 and 69 cases per 100,000 population per year. Of these patients, approximately one-third present with clinical symptoms of acute pulmonary embolism (PE) and two-thirds with deep venous thrombosis (DVT). Recent registries and cohort studies suggest that approximately 10% of all patients with acute PE die during the first 1 to 3 months after diagnosis. Overall, 1% of all patients admitted to hospitals die of acute PE, and 10% of all hospital deaths are PE-related. These facts emphasize the need to better implement our knowledge on the pathophysiology of the disease, recognize the determinants of death or major adverse events in the early phase of acute PE, and most importantly, identify those patients who necessitate prompt medical, surgical, or interventional treatment to restore the patency of the pulmonary vasculature.

[Fulminant pulmonary artery embolism in the early postoperative phase. Use of transesophageal echocardiography in acute diagnostics]

Acute pulmonary embolism is a serious perioperative complication with a high mortality. A case of early onset pulmonary embolism with acute right heart failure and resuscitation after spinal surgery is reported. The diagnosis was rapidly and reliably confirmed by transesophageal echocardiography (TEE) and a right atrial thrombus was detected. Persistent life-threatening hemodynamic instability required thrombolysis with 100 mg recombinant tissue-type plasminogen activator (rt-PA). The patient survived this critical situation but sustained permanent paraparesis.

Echocardiographic diagnosis, management and monitoring of pulmonary embolism with right heart thrombus in a patient with myotonic dystrophy: a case report

Acute pulmonary embolism (PE) is a common disease which frequently results in life-threatening right ventricular (RV) failure. High-risk PE, presenting with hypotension, shock, RV dysfunction or right heart thrombus is associated with a high mortality, particularly during the first few hours. Accordingly, it is important to commence effective therapy as soon as possible. In the case described in this report, a 49-year-old woman with myotonic dystrophy type 1 presented with acute respiratory failure and hypotension. Transthoracic echocardiography showed signs of right heart failure and a mobile right heart mass highly suspicious of a thrombus. Based on echocardiographic findings, acute thrombolysis was performed resulting in hemodynamic stabilization of the patient and complete resolution of the right heart thrombus. This case underscores the important role of transthoracic echocardiography for the diagnosis, management and monitoring of PE and underlines the efficacy and safety of thrombolysis in the treatment of PE associated with right heart thrombus.

Right cardiac thrombus in transit among patients with pulmonary thromboemboli

BACKGROUND

This study was designed to investigate the prevalence, clinical and laboratory findings, and short-term prognostic significance of mobile right cardiac thrombus (MRCT) among patients with pulmonary thromboembolism (PTE).

METHODS

From January 2004 to November 2006, 12 of 100 patients admitted with a diagnosis of PTE had an MRCT. Diagnosis of in-transit right-sided thrombi was made when a wormlike elongated mass was detected. The primary end point was comparison of the mortality rate of MRCT (+) patients with that of MRCT (-) patients for an average of 8 months of follow-up. The secondary end points were comparison of clinical and laboratory data between these 2 groups.

RESULTS

All MRCT (+) patients but 1 had dyspnea, but just 2 patients had syncope during exertion. The most frequent electrocardiographic finding was T inversion in leads V1-V3 (75%). All 6 of the MRCT (+) patients who had a cardiac arrest in the hospital died in the hospital. In comparison, of the 88 MRCT (-) patients, 12 had a cardiorespiratory arrest, 4 of whom survived (hospital mortality rate of 50% versus 9%, respectively).

CONCLUSIONS

It seems that the presence of MRCT has prognostic significance, predicting a higher-than-average mortality rate.

Critical appraisal on the utility of echocardiography in the management of acute pulmonary embolism

Echocardiography can be used for rapid and accurate risk stratification of patients with pulmonary embolism to appropriately direct the therapeutic strategies for those at high risk. Echocardiography is an ideal risk stratification tool in this regard because of its easy portability to the emergency room or to the bed side. It can be performed at a relatively low cost and at no risk to the patient. Furthermore, echocardiography allows repetitive noninvasive assessment of the cardiovascular and hemodynamic status of the patient and the response to the therapeutic interventions. Right ventricular hypokinesis, persistent pulmonary hypertension, a patent foramen ovale, and a free floating right heart thrombus are echocardiographic markers that identify patients at a higher risk for morbidity and mortality. Such patients warrant special consideration for thrombolysis or embolectomy.

[Diagnosis, therapy and secondary prophylaxis of acute pulmonary embolism. Presentation of and commentary on the new ESC 2008 guidelines]

Acute venous thromboembolism is a common cardiovascular emergency. Acute pulmonary embolism (PE) is present in one third of these patients. With an average lethality rate of 11% within the first two weeks following diagnosis, approximately 40,000 patients in Germany die annually as a result of PE; therefore, their diagnosis and therapy is of particular importance. For this reason, the European Society of Cardiology published guidelines on diagnosis and therapy in 2000. The current article presents and discusses the points as updated and extended in the 2008 version of the guidelines, including: (1) initial risk stratification--when PE is already suspected; (2) diagnostic procedures and algorithms; (3) further risk stratification; (4) therapeutic strategies in the acute phase; (5) further management and (6) long-term anticoagulation and secondary prophylaxis.

Prevalence of heart diseases in patients with pulmonary embolism with and without peripheral venous thrombosis: findings from a cross-sectional survey

BACKGROUND

In up to 80% of patients with pulmonary embolism (PE) no peripheral symptomatic thrombosis can be identified. Whether the heart may represent a source of PE is unknown.

METHODS

We conducted a cross-sectional survey of patients who were 60 years or older and were discharged from the hospitals of Veneto region, Italy between 2000 and 2006 with the diagnosis of PE. We compared the prevalence of several acute and chronic heart diseases in patients discharged with the diagnosis of PE alone with that of patients with co-occurring symptomatic peripheral deep venous thrombosis (PE/DVT).

RESULTS

Out of 11,236 eligible patients, 9079 (81%) were discharged with the diagnosis of PE alone, and 2157 with that of PE/DVT. 3239 of the 9079 (35.7%) patients with isolated PE, and 666 of the 2157 (30.9%) with PE/DVT had at least one heart disease. The adjusted odds ratio (OR) for having at least one heart disease in patients with isolated PE as compared to those with PE/DVT was 1.26 (95% CI, 1.13-1.40). The heart diseases that significantly contributed to the study results were all-cause cardiomyopathies (adjusted OR, 2.31; 95% CI, 1.37-3.89), all-cause heart failure (1.82; 1.45-2.27), coronary heart disease (1.28; 1.08-1.52), and atrial fibrillation or flutter (1.28; 1.08-1.51).

CONCLUSIONS

There is an association between isolated PE and a number of heart diseases. The results of our survey generate the hypothesis that in older patients several heart diseases may directly account for the development of PE. Prospective studies are needed to confirm this hypothesis.

[Update in pulmonary thromboembolic disease]

Pulmonary embolism is part of venous thromboembolism, an important health problem which leads to significant mortality and morbidity with high economic and social burden. A prompt diagnosis and treatment as well as an appropriate prophylaxis are determinant factors in prognosis. This disease continues to demand particular attention namely in the investigation of risk factors, clinical probability algorithms development, diagnostic work-up evaluation, characterization of new therapeutic strategies and thromboprophylaxis recommendations. The present review looks into the current scientific knowledge regarding pulmonary embolism.

Impending paradoxical embolism: systematic review of prognostic factors and treatment

BACKGROUND

Little is known about the optimal management of impending paradoxical embolism (IPDE), a biatrial thromboembolus caught in transit across a patent foramen ovale. Our aim was to review observational studies on this subject to identify prognostic factors and to compare mortality and systemic embolism between treatments.

METHODS

Systematic literature searches in Medline, Embase, and Cochrane Library identified 154 studies (174 patients). The primary end point was 30-day mortality. The secondary end point was systemic embolism during treatment.

RESULTS

Thirty-day mortality was 18.4%. On univariate analysis, age (64+/-13.9 vs 56.7+/-16.5; P = .01), coma (12.9% vs 2.2%; P = .02), and systemic embolism (71.9% vs 51.4%; P = .048) at presentation were significantly increased among nonsurvivors. Surgical thromboembolectomy had lower mortality than other treatment groups (10.6%; P = .04). In multivariable models, no prognostic factor was a significant independent predictor of mortality. Surgically treated patients had nonsignificantly reduced mortality (odds ratio [OR], 0.65 [0.24-1.72]; P = .65) and thrombolysis-treated patients had increased mortality (OR, 1.62 [0.43-5.97]; P = .47). However, systemic embolism during treatment and combined mortality and systemic embolism was decreased in the surgery group (OR, 0.13 [0.03-0.67]; P = .02 and OR, 0.26 [0.11-0.60]; P = .001).

CONCLUSIONS

This review attempts to help guide what to do in IPDE, despite severe limitations of the methods. Surgical thromboembolectomy showed a nonsignificant trend toward improved survival, significantly reduced systemic embolism, and composite of mortality and systemic embolism, compared with anticoagulation alone. Thrombolysis, on the other hand, had the opposite effect, although not significantly.

A floating thrombus of the right ventricle in severe massive pulmonary embolism

Floating right heart thrombus (FRHT) is a severe presentation of thromboembolic disease and usually coexists with massive pulmonary embolism. Patients with FRHT are more hemodynamically compromised and usually have a higher mortality rate than patients without FRHT. An echocardiographic finding of FRHT is important because it identifies as poor prognosis. The optimal treatment in patients with FRHT remains uncertain. Heparin is more often an anticoagulant than a lytic agent. Several studies suggested that thrombolytic therapy has advantages in treating such patients. Early diagnosis and emergency therapy are important in treating patients with FRHT in the emergency department and they might have fatal outcomes when treated only with heparin.

A critical review of thromboembolic complications associated with central venous catheters

PURPOSE

Central venous catheters (CVC) are commonly used in critical care. While thrombosis is a well-recognized and frequent complication associated with their use, CVC-related thromboembolic complications, including pulmonary embolism (PE) and right heart thromboembolism (RHTE), occur less frequently and often evade diagnosis. Little information exists to guide clinicians in the diagnosis and management of CVC-related thromboembolic complications.

SOURCE

We critically review and synthesize the literature highlighting the incidence of CVC-related thrombosis. We highlight the risk for developing thromboembolic complications and provide approaches to diagnosing and managing RHTE.

PRINCIPLE FINDINGS

The incidence of CVC-related thrombosis varies depending on patient, site, instrument, and infusate-related factors. Central venous catheters-related thrombosis represents an important source of morbidity and mortality for affected patients. Pulmonary embolism occurs in approximately 15% of patients with CVC-related upper extremity deep venous thrombosis (UEDVT). More frequent use of transesophageal echocardiography, in patients with suspected and confirmed PE, has resulted in increased detection of RHTE. While it is recognized that the occurrence of RHTE, in association with PE, increases mortality, the optimal strategy for their management has not been established in a clinical trial.

CONCLUSION

Central venous catheter-related thrombosis occurs frequently and represents an important source of morbidity and mortality for affected patients. Our review supports that surgery and thrombolysis have both been demonstrated to enhance survival in patients with RHTE and PE. However, important patient, clot, and institutional considerations mandate that treatment for patients with RHTE and PE be individualized.

Free floating right atrial thrombus leading to acute pulmonary embolism

The presence of right heart thrombi appears to increase the risk of mortality compared to the presence of pulmonary thromboemboli alone. The increased use of two-dimensional echocardiography has led to increased detection of these thromboemboli, particularly in patients with suspected or confirmed pulmonary emboli. The optimal management of the right heart thromboemboli remains unclear, but thrombolytic therapy with rt-PA appears to be rapidly effective in most patients resulting with complete resolution of the thrombus and improvement of pulmonary perfusion. Here, we present a case of free floating, worm-like thrombus in the right atrium which was lysed successfully by fibrinolytic therapy in a patient presenting with acute massive pulmonary embolism.

Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)

Non-thrombotic PE does not represent a distinct clinical syndrome. It may be due to a variety of embolic materials and result in a wide spectrum of clinical presentations, making the diagnosis difficult. With the exception of severe air and fat embolism, the haemodynamic consequences of non-thrombotic emboli are usually mild. Treatment is mostly supportive but may differ according to the type of embolic material and clinical severity.

Tricuspid valve thrombus: a case report associated with gonadotropin-releasing hormone analogue therapy and review of the literature

A 35-year-old woman with a previously repaired atrial septal defect was referred for preoperative evaluation before laparoscopic surgery. The patient was asymptomatic, and a transesophageal echocardiographic examination revealed a probable thrombus attached to the tricuspid valve. The patient's history included therapy with a gonadotropin-releasing hormone analogue and deep venous thrombosis five months earlier. The tricuspid valve thrombus disappeared after anticoagulant therapy. Warfarin was initiated for prophylaxis. During the follow-up, the patient was event-free during laparoscopic surgery and pregnancy (when warfarin was switched to acetylsalicylic acid) and gave birth to a healthy term baby. Because etiological investigations revealed no reason for the tricuspid valve thrombus, it was considered to be related to the procoagulant state induced by hormonal treatment. The patient was scheduled for close follow-up.

An unusual right heart mass

A mobile right atrial mass, prolapsing into the right ventricle and extending to the inferior vena cava, was unexpectedly discovered during a routine echocardiographic examination in a 53-year- old woman. A possible tumour was suspected, but no evidence of primary malignancy was detected in lungs, liver, kidneys and adrenal glands. The patient underwent surgery, and only histological examination of the mass provided a final diagnosis of thrombosis.

The right atrial thrombus: the sword of Damocles with real risk of massive pulmonary embolism

Cases of 6 patients admitted at the intensive care unit for massive pulmonary embolism are reported. All patients presented with dyspnea, tachypnea, and tachycardia, and 4 were hypotensive and had syncope. Lung ventilation/ perfusion scans revealed perfusion defects in 4 patients. Transthoracic echocardiography (TTE) demonstrated acute cor pulmonale. It also revealed mobile right atrial thrombi in 5 patients, adherent thrombus in the right atrium in 1 patient and patent foramen ovale in 4 patients. Thrombolytic therapy was initiated in 4 patients, and 2 patients received heparin infusion only. Effects of thrombolysis were monitored using bedside TTE during the first 24 hours and in follow-up. The outcome of 4 patients who received thrombolytic therapy was good whereas other 2 patients, who received only heparin, died. Thrombotic mass disappeared 8 to 12 hours after initiation of therapy, and 10 weeks after discharge TTE showed normalized right ventricle dimensions and function in all 4 patients.

What to do with an atrial thrombus?

This case report is about an 84-year-old woman admitted with right atrial thrombus attached to a pacemaker lead, diagnosed by transesophageal echocardiography. Surgical treatment was rejected due to the high operative risk, and percutaneous stenting was performed with success; unfortunately, the outcome was fatal and the patient died. We review here the clinical features of right atrial thrombi, including the epidemiology, clinical manifestations, diagnosis, and treatment, which is sometimes controversial.

Taenia cordis

Free-floating right heart thrombi are rare echocardiographic findings usually encountered in patients with massive pulmonary embolism and associated with poor prognosis. We report a case of a large free-floating right heart thrombus without clinically significant pulmonary embolism. The patient was treated conservatively with heparin and warfarin, and the thrombus resolved uneventfully.

Is right heart thromboemboli another indication for thrombolysis?

Pulmonary embolism (PE) is a common and a potentially life-threatening disease. Diagnosis is challenging because the signs and symptoms are non-specific. Moreover treatment of PE is shrouded in controversy. Even at presentation the role of thrombolysis in managing patients with PE remains unclear. In those patients with right heart thromboemboli, thrombolysis is usually suggested, but the evidence remains unclear. We report a 34-year-old man who was diagnosed with right heart thromboemboli on echocardiography and was successfully managed with thrombolysis and anticoagulation. We also review the current published work on the management of patients with right heart thromboemboli.

Successful Treatment of Right Ventricular Thrombus with Heparin and Sodium Warfarin Therapy: A Case Report

A 75-year-old woman came to our emergency clinic complaining of abdominal pain. Acute cholecystitis was diagnosed, and parenteral antibiotic therapy was initiated. Because of palpitation, she had a consultation with the cardiology clinic. Echocardiography showed a 2.7 x 2.2 cm mobile thrombus attached to the apex of the right ventricle. Since no thromboembolic complications were present, we decided to begin administering heparin and oral anticoagulant. After the administration of unfractionated heparin for 48 hours, the patient was shifted to low-molecular weight heparin because it is easier to use and requires no follow-up. The patient received low-molecular weight heparin in addition to sodium warfarin for 5 days. Administration of heparin was then stopped and treatment was continued with sodium warfarin. In the series of weekly echocardiography evaluations, a gradual reduction was noted in the apical mass, which was initially considered to be a thrombus, and 3 weeks later evaluation revealed that the thrombus in the right ventricle had disappeared completely. No thromboembolic complications were observed during the follow-up period.

Management of unsuccessful thrombolysis in acute massive pulmonary embolism

BACKGROUND

The management of patients with acute massive pulmonary embolism (PE) who do not respond to fibrinolytic therapy remains unclear. We aimed to compare rescue surgical embolectomy and repeat thrombolysis in patients who did not respond to thrombolysis.

METHODS

We conducted a prospective single-center registry of PE patients who underwent thrombolytic therapy. Lack of response to thrombolysis within the first 36 h was prospectively defined as both persistent clinical instability and residual echocardiographic right ventricular dysfunction. Patients underwent surgical embolectomy or repeat thrombolysis, at the discretion of the attending physician. The clinical end point was a combined end point including recurrent PE, bleeding complications, or PE-related death, which was defined as death from recurrent PE or cardiogenic shock. Long-term adverse outcomes included death, recurrent thromboembolic events, and congestive heart failure.

RESULTS

From January 1995 to January 2005, 488 PE patients underwent thrombolysis, of whom 40 (8.2%) did not respond to thrombolysis. Fourteen patients were treated by rescue surgical embolectomy, and 26 were treated by repeat thrombolysis. There was no significant difference in baseline characteristics between the two groups. The in-hospital course was uneventful in 11 of the surgically treated patients (79%) and in 8 patients (31%) treated by repeat thrombolysis (p = 0.004). There was a trend for higher mortality in the medical group than in the surgical group (10 vs 1 deaths, respectively; p = 0.07). There were significantly more recurrent PEs (fatal and nonfatal) in the repeat-thrombolysis group (35% vs 0%, respectively; p = 0.015). While no significant difference was observed in number of major bleeding events, all bleeding events in the repeat-thrombolysis group were fatal. The rate of uneventful long-term evolution was the same in the two groups.

CONCLUSION

Rescue surgical embolectomy led to a better in-hospital course when compared with repeat thrombolysis in patients with massive PE who have not responded to thrombolysis. The transfer of patients who have not responded to thrombolysis to tertiary cardiac surgery centers could be considered as an alternative option.

A positive outcome in patient with massive acute pulmonary embolism and right atrial mobile thrombus fragmented during thrombolysis: a serial echocardiographic examination

The case report presents a patient with acute, massive pulmonary embolism diagnosed by transthoracic echocardiography, with the mobile thrombus visualized in the right atrium. During the thrombolytic therapy the thrombus was fragmented and migrated to the pulmonary artery, with a rapid transient worsening of the clinical status of the patient. The continuation of thrombolysis led to the gradual improvement of the patient condition. In this case report the importance of serial echocardiographic examinations in revealing right heart masses, the right ventricle overloading and the effectiveness of treatment is shown.

Mobile thrombi of the right heart in pulmonary embolism: delayed disappearance after thrombolytic treatment

BACKGROUND AND OBJECTIVE

In patients presenting with pulmonary embolism (PE), echocardiography, in some cases, reveals mobile clots in right heart (RH) cavities. How these clots evolve after treatment, in particular after thrombolytic treatment (TT), is unknown. We sought to determine the outcome of these mobile clots in the RH during TT.

METHODS AND RESULTS

Of a series of 343 patients who had been hospitalized for PE in our department, echocardiography performed on hospital admittance showed a mobile clot in the RH in 18 patients (mobile clot incidence, 5.2%). This subgroup of 18 patients presented with a more severe form of PE than the 325 patients without mobile clots in the RH. In our series, 16 patients were treated with thrombolytic agents. Close echocardiography monitoring showed the outcomes of these mobile clots during and after TT. In 50% of cases, the clot disappeared rapidly in < 2 h after the end of TT. In 50% of the remaining cases, the clot disappeared later, half within 12 h following the completion of TT, and the other half within 24 h. All patients were alive on day 30 without any clinical sequellae.

CONCLUSION

In these particular forms of PE with mobile clots in the RH, the short time lag required to disperse the clot after TT makes it imperative to delay any decision about new aggressive therapy.

Calcified right ventricular mass and pulmonary embolism in a previously healthy young woman

A 20-year-old woman with a recent episode of pulmonary embolism was found by echocardiographic examination to have a calcified apical right ventricular intracavitary mass. She had a history of cigarette smoking and had been taking oral contraceptive pills. At age 17 years, she had sustained substantial blunt chest injury during a motor vehicle accident. The intracardiac mass was resected and represented an old calcified mural thrombus. It is postulated that its development was related to cardiac trauma. These intracavitary masses have been referred to as cardiac calcified amorphous tumors and generally represent old organized and focally calcified mural thrombus. They should be distinguished from calcified benign or malignant neoplasms of the heart.

Prevalence and risk of pulmonary embolism in patients with intracardiac thrombosis: a population-based study of 23 796 consecutive autopsies

AIMS

While right intracardiac thrombosis (IT) is a potential cause of pulmonary embolism (PE) similar to that of stroke in left-sided IT, its prevalence and prognostic significance has not been studied in the general population. The aim of this study was to assess the age- and gender-specific prevalence of IT and its relation to PE in a population-based autopsy cohort.

METHODS AND RESULTS

Between 1970 and 1982, 23 796 autopsies, representing 84% of all in-hospital deaths in the Malmö city population, were performed, using a standardized procedure. The relationship between IT and PE was evaluated by cohort analyses and nested case-control studies. IT was present in 1706 (7.2%) patients, 727 and 747 of whom had right and left atrial IT, respectively. PE prevalence in patients with isolated left IT, isolated right IT, and combined IT was 28.5, 35.6, and 48.9%, with RR (95% CI) of 1.5 (1.3-1.8), 2.0 (1.6-2.5), and 3.5 (2.7-4.7), respectively, compared with age- and gender-matched controls. Patients dying from ischaemic heart disease had a 3.2 (2.7-3.6) times higher risk of right IT, which was associated with 43% PE prevalence. Of all patients with PE at autopsy, right IT was found in 354 (6.5%), and the only detected source of PE in 220 (4.0%).

CONCLUSION

Right cardiac thrombosis, though difficult to assess clinically, is as common as left cardiac thrombosis and is associated with an increased risk of PE. The diagnosis should be considered in all cases of PE, especially in patients with atrial fibrillation or myocardial infarction and in the absence of confirmed deep vein thrombosis.