Free-floating right atrial thrombus with acute pulmonary embolism

Pulmonary embolism with floating right atrial thrombus successfully treated with streptokinase: a case report

Background

Massive pulmonary embolism (PE) is associated with significant mortality, especially if compounded by haemodynamic instability, right ventricular (RV) dysfunction and right atrial (RA) thrombus. Thrombolysis can be lifesaving in patients with major embolism and cardiogenic shock, and accelerates the resolution of thrombus. Only three fibrinolytic agents—namely streptokinase, urokinase, and recombinant tissue plasminogen activator (alteplase) have been approved in the treatment of PE, with studies demonstrating similar safety profiles.

Case presentation

We report the case of a 33-year-old Bangladeshi Bengali female with a history of recent ankle fracture and immobilization, who presented with massive PE, leading to cardiac arrest. Upon rapid resuscitation, urgent echocardiogram revealed RV dysfunction with floating RA thrombus, and she was successfully treated with 1.5 million IU of streptokinase over 2 h as per accelerated regimen recommended by the European Society of Cardiology guidelines, resulting in successful resolution of the right heart thrombus, and significant clinical improvement. Subsequent CT pulmonary angiogram confirmed the diagnosis of PE, and she was anticoagulated to a PT/INR of 2.0–3.0 for 3 months.

Conclusions

Echocardiography is a suitable alternative for rapid diagnosis of acute massive PE associated with RA thrombus and cardiovascular collapse, especially when a delay to CT pulmonary angiogram may be anticipated, and in the setting of immediate cardio-pulmonary resuscitation. Thrombolysis is a rapid and life-saving therapeutic measure in such cases.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-016-2177-1) contains supplementary material, which is available to authorized users.

Pulmonary ultrasound examination for edema, effusion, and thromboembolism

Bedside, or point-of-care, ultrasound (US) has increasingly been used in various clinical settings to provide clinicians with rapid clinical information without the use of ionizing radiation. Lung US has been demonstrated as a valuable tool in the diagnosis and evaluation of pulmonary edema, pleural effusions, and pulmonary thromboembolism. Lung US enables the clinician to more quickly identify and initiate treatment for these potentially life-threatening conditions without the need for patient transportation to the radiology suite. Additionally, lung US can repeatedly be implemented to assess clinical changes without concern for repeated radiation exposure and is cost-effective given its ability to decrease the need for additional radiological and laboratory testing to confirm a suspected diagnosis. This review focuses on the application of lung US in the evaluation and management of pulmonary edema, pleural effusions, and pulmonary thromboembolism.

Asymptomatic free-floating thrombus of the internal carotid artery

Free-floating thrombus (FFT) of the internal carotid artery, which is almost always symptomatic and is usually discovered by ultrasound or angiography performed after a transient cerebrovascular event, is a highly uncommon diagnosis. Here, we report a case of an asymptomatic freefloating internal carotid artery thrombus most probably caused by an atherosclerotic plaque rupture. It was detected by carotid ultrasound and was treated with eversion endarterectomy without any neurologic complications. Six weeks after surgery, the patient is doing well.