Right heart thrombi (RHT) and clot in transit with concomitant PE management: Approach and considerations

Chronic Thromboembolic Pulmonary Artery Hypertension or Fibrosing Mediastinitis?

We report a case of pulmonary hypertension in association with right heart thrombus and mediastinal lymphadenopathy leading to the diagnostic dilemma of chronic thromboembolic pulmonary hypertension vs fibrosing mediastinitis despite of extensive noninvasive workup, considering different treatment strategies and therapeutic implications. Surgical findings provided a conclusive diagnosis and excellent prognosis.

Thrombus in Transit: Key Echocardiography Findings in the ED

A 32-year-old Asian male presented to the ED with a one-day history of mild pleuritic chest pain. He was diagnosed with an acute pulmonary embolus on CT Pulmonary Angiography (CT-PA). Transthoracic echocardiography (TTE) performed at the bedside in the ED demonstrated evidence of right heart strain but, most notably, a highly mobile echogenic thrombus in the right atrium, consistent with a clot-in-transit (CIT). This was not visualized on CT due to the influx of contrast in the heart. Based on this, the patient was transferred to the High Dependency Unit for IV heparin and close monitoring. The following day, he underwent clot retrieval using an Inari Flowtriever under direct TTE guidance. He was discharged on oral anticoagulation four days later and experienced no complications on follow-up. CIT is an important feature of pulmonary embolus to identify, as it can escalate the risk stratification of the patient, and management will need to be altered accordingly.

Pulmonary Embolism With Multiple Active Right Ventricular Thrombi in Transit Managed Using Anticoagulation With and Without Inferior Vena Cava Filter: A Report of Two Oncology Patients

Pulmonary embolism (PE) in the context of a right ventricular (RV) thrombus in transit is a special situation requiring a quick response that differs according to many factors. It is a rare but alarming finding. There is no clear guide to date that outlines a common pathway for treatment, as many factors play a role in determining the treatment plan. The mere presence of a thrombus in transit in the right atrium or right ventricle with a concomitant PE carries a higher risk of morbidity and mortality than PE alone. We will examine two cases presenting with PE with concomitant RV multiple thrombi and a background of cancer and diffuse bilateral deep vein thrombosis. One case was treated with anticoagulation alone, and the other with an inferior vena cava (IVC) filter in addition to anticoagulation. They both had a stable course despite their high risks and the frightening appearance of the multiple floating and attached thrombi seen in their echocardiography, some of which newly appeared after the second day of anticoagulation. The cases reflect the effectiveness of echocardiography for detecting and guiding treatment even after starting anticoagulation as well as the good outcome in such cases with anticoagulation alone when no massive PE occurs.

Pulmonary Embolism: An Update Based on the Revised AWMF-S2k Guideline

Pulmonary embolism (PE) is the third most common acute cardiovascular disease. The risk of PE increases with age and mortality is high. Patients are stratified into hemodynamically stable versus unstable patients, as this has important implications for diagnosis and therapy. Since clinical signs and symptoms of acute PE are nonspecific, the clinical likelihood of PE is estimated to guide diagnostic pathways. D-dimer testing is performed in hemodynamically stable patients with low or intermediate probability of PE and the visualization of thromboembolism and its sequelae is commonly achieved with computed tomography pulmonary angiography (CTPA), supplemented by ultrasound techniques. With confirmed PE, another risk stratification estimates disease severity and defines intensity and setting of the ensuing treatment. The therapeutic spectrum ranges from outpatient treatment with initial oral anticoagulation to thrombolytic or interventional treatment in the intensive care unit or catheterization laboratory. In single cases, even acute surgical thrombectomy is attempted.

Clinical Outcomes and Predictors of Advanced Therapy for the Management of Right Heart Thrombus

BACKGROUND

The role of advanced therapies (systemic thrombolysis, catheter-based treatment, and surgical thrombectomy) for the management of right heart thrombus is poorly defined. In this study, we assessed the clinical predictors and outcomes of advanced therapy compared with anticoagulation alone for the acute management of right heart thrombus.

METHODS

In this observational cohort study, we analyzed consecutive patients who were treated for right heart thrombus. The primary end point was 90-day all-cause mortality. Clinical predictors of utilizing advanced therapy were assessed with multivariable logistic regression. Propensity score matching was utilized to compare adjusted outcomes between patients receiving advanced therapies versus anticoagulation alone.

RESULTS

A total of 345 patients were included in the study. Advanced therapy was utilized in 13.6% (N=47) of patients, of which 25.5% (N=12/47) was systemic thrombolysis, 23.4% (N=11/47) was endovascular thrombectomy, and 53.2% (N=25/47) was surgical thrombectomy. Younger age (odds ratio, 0.98 [95% CI, 0.96-0.99]) and concurrent pulmonary embolism (odds ratio, 5.36 [95% CI, 2.48-12.1]) predicted utilization of advanced therapy. In propensity score-matched analysis, there was no difference in 90-day mortality (hazard ratio, 0.46 [95% CI, 0.17-1.22]), in-hospital mortality (odds ratio, 0.64 [95% CI, 0.17-2.19]), or length of stay (β, -4.39 [95% CI, -14.0 to 5.22]) between advanced therapy and anticoagulation.

CONCLUSIONS

Among a diverse cohort of patients with right heart thrombus, outcomes did not differ between those who underwent advanced therapy and anticoagulation alone. Important predictors for utilizing advanced treatment included younger age and the presence of a concurrent pulmonary embolism. Future studies assessing advanced therapy in larger and broader patient populations are necessary.

Endovascular aspiration of native tricuspid valve vegetation using INARI catheter in a patient with methicillin-sensitive Staphylococcus aureus endocarditis

A middle-aged man presented to the hospital with chief complaint of worsening chest pain and shortness of breath. He was found to have methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia, acute hypoxic respiratory failure secondary to MSSA pneumonia and septic emboli. The patient underwent a transesophageal echocardiogram which revealed a large, mobile tricuspid valve vegetation secondary to endocarditis. The patient was initially managed conservatively with intravenous antibiotics and supportive measures. However, his respiratory status worsened due to persistence of a large tricuspid valve vegetation which progressed to bilateral septic pulmonary emboli with peripheral cavitary lesions identified on follow-up CT of the chest. In order to debulk the large tricuspid vegetation, the patient successfully underwent endovascular mechanical aspiration of tricuspid valve vegetation utilizing the 20-Fr INARI curved Flowtriever (INARI Medical, CA) catheter. This case highlights a new, minimally invasive technique and device employed in treating native valve vegetations caused by endocarditis as an alternative approach to surgery.

High-Risk Pulmonary Embolism: Management for the Intensivist

High-risk pulmonary embolism (PE) also known as massive PE carries a high rate of morbidity and mortality. The incidence of high-risk PE continues to increase, yet the outcomes of high-risk PE continue to remain poor. Patients with high-risk PE are often critically ill, with complex underlying physiology, and treatment for the high-risk PE patient almost always requires care and management from an intensivist. Treatment options for high-risk PE continue to evolve rapidly with multiple options for definitive reperfusion therapy and supportive care. A thorough understanding of the physiology, risk stratification, treatment, and support options for the high-risk PE patient is necessary for all intensivists in order to improve outcomes. This article aims to provide a review from an intensivist's perspective highlighting the physiological consequences, risk stratification, and treatment options for these patients as well as providing a proposed algorithm to the risk stratification and acute management of high-risk PE.

Debulking the tricuspid valve with FlowTriever aspiration: A case series

Intracardiac masses adhering to the tricuspid valve can occur as a result of right-sided infective endocarditis, malignancy, clot formation in the right atrium, or clots-in-transit passing through the right atrium. Early surgical intervention is recommended for tricuspid valve vegetation in some patients, although open heart surgery is not always an option. Treatment options for right heart thrombi include anticoagulation, thrombolysis, surgical embolectomy, or mechanical aspiration. We present a case series of tricuspid valve debulking using aspiration with the FlowTriever System.

Clinical Significance of Right Heart Thrombus With and Without an Associated Pulmonary Embolism

BACKGROUND

Right heart thrombus is a rare but serious form of venous thromboembolic disease that may be associated with pulmonary embolism. The prognosis of patients with right heart thrombus presenting without a concomitant pulmonary embolism remains ill-defined.

METHODS

We conducted a multi-center observational cohort study to compare patients presenting with right heart thrombus with and without a concurrent pulmonary embolism. The primary endpoint was 90-day all-cause mortality. Multivariable regression was utilized to assess primary and secondary outcomes.

RESULTS

Of 231 patients with right heart thrombus, 104 (45.0%) had a pulmonary embolism at admission. The median age of the cohort was 59.4 years (interquartile range 44.9-71.3). Pulmonary embolism in the setting of a right heart thrombus was associated with an increased adjusted hazard of 90-day mortality (hazard ratio 3.68; 95% confidence interval [CI], 1.51-8.97). Additionally, these patients had a higher adjusted risk of in-hospital mortality (odds ratio [OR] 2.55; 95% CI, 1.15-5.94) and admission to the intensive care unit (OR 2.45; 95% CI, 1.23-4.94). Thrombus mobility (OR 2.99; 95% CI, 1.35-6.78) and larger thrombus sizes (OR 1.04; 95% CI, 1.00-1.07) were associated with development of concurrent pulmonary embolism.

CONCLUSIONS

Patients with right heart thrombus and pulmonary embolism had a more severe clinical presentation, required more advanced therapies, and had reduced survival compared with those without a concomitant pulmonary embolism. Important variables associated with development of concomitant pulmonary embolism include thrombus mobility and size. Right heart thrombus in the setting of acute pulmonary embolism represents a unique clinical entity that is associated with worse prognosis compared with right heart thrombus only.

Mechanical Thrombectomy for a Clot in Transit With Adherence to the Tricuspid Valve

This case report investigates the management of a clot in transit (CIT), a rare but possibly life-threatening condition discovered in a small percentage of pulmonary embolism (PE) cases. CITs are thrombi lodged within the right-side heart chambers or the major veins, and there are currently no universal guidelines for their management though the literature has shown reduced mortality with reperfusion therapy compared to anticoagulation alone. In this case, a 96-year-old male who presented with a submassive PE was initially stabilized with anticoagulation and was then discovered to have a CIT with adherence to the tricuspid valve. The patient underwent a successful mechanical thrombectomy using the Inari FlowTriever (Inari Medical, Irvine, CA), an FDA-approved device for CIT removal. Overall, this manuscript supports this percutaneous intervention in intermediate to high-risk PE patients with concomitant CIT, offering an alternative to thrombolysis and cardiothoracic surgery, which carry their own risks. Furthermore, the unique characteristic of the CIT in this patient suggests a potential for further investigation into the diversity of CIT morphology and its significance.

Becker muscular dystrophy and successful intervention with mechanical thrombectomy of right atrial clot-in-transit with pulmonary embolism

This case report discusses the effectiveness of the Inari FlowTriever system in treating a right atrial (RA) clot in-transit in a 55-year-old male patient with Becker's muscular dystrophy (BMD). BMD is an X-linked recessive muscle disease caused by mutations in the gene that code for the protein dystrophin, which is associated with partially functional dystrophin in variable amounts. Right heart thrombi (RHT) are thrombi that can be visualized in the right atrium, right ventricle, or proximal surrounding vasculature. The Inari FlowTriever system was used to treat RA clot in-transit and removed acute, subacute, and chronic clot in a single session without the use of thrombolytics and subsequent ICU stay. The estimated blood loss with the FlowSaver system was approximately 150 mL. This report complements the FLARE study by highlighting the effectiveness of the FlowTriever system for mechanical thrombectomy of RA clot-in-transit in a patient with BMD.

Clot-in-transit: A ticking time bomb in the heart with serious consequences

Clot-in-transit is associated with severe pulmonary embolism and higher mortality than acute pulmonary embolism without clot-in-transit. The optimal treatment of clot-in-transit is not established. Multiple treatment options have been described, including anticoagulation alone, systemic thrombolysis, surgical embolectomy and endovascular catheter-based therapies. Clot-in-transit can embolize to the pulmonary circulation in a matter of seconds and be immediately fatal. We describe two cases of clot-in-transit which embolized quickly upon Intensivist's evaluation and were associated with serious consequences. Management decisions for clot-in-transit should be emergent and based on multidisciplinary discussion of the pulmonary embolism response team.

A Proposed Approach for the Management of Clot-in-Transit

Clot-in-transit (CIT) is defined as a mobile echogenic material in the right atrium or ventricle as observed on ultrasound. A right heart free-floating thrombus is unusual when there is no structural disease of the heart or atrial fibrillation. Cardiopulmonary collapse and quick death can come from CIT, which occurs when a blood clot moves from the heart to the lungs. There are some clinical case reports of a large volume thrombus that was freely floating in the right heart in an asymptomatic patient, and the best therapeutic options are uncertain. Although several trials have been conducted on the treatment of CIT, clinical judgment is still used to determine the best treatment for right heart thrombus (RHT), especially when associated with pulmonary embolism (PE). In this review article, we discuss various diagnostic modalities and treatment options for this rare malady. We studied in detail their clinical impact on patients according to past research studies.