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Ji J, Jiang L, Wang W, Chi X, Dong J, Lu L, Huang M, Wei X, Pang G, Pang J, Xiong B, Xiang S. AngioJet thrombectomy with extracorporeal membrane oxygenation support for an acute large-scale pulmonary embolism with bilateral atrial thrombosis: a case report of catastrophic antiphospholipid syndrome. Front Cardiovasc Med 2024; 11:1409775. [PMID: 39015680 PMCID: PMC11249738 DOI: 10.3389/fcvm.2024.1409775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 06/11/2024] [Indexed: 07/18/2024] Open
Abstract
Background Catastrophic Antiphospholipid Syndrome (CAPS), a severe systemic autoimmune disorder, predominantly causes life-threatening multi-organ failure, with a high mortality rate. It primarily affects small vessels, seldom impacting large vessels. Notably, acute massive pulmonary embolism (PE) with bilateral atrial thrombosis is an exceptional occurrence in CAPS. Acute pulmonary embolism (PE) is a common cardiovascular disease that progresses rapidly and has a high mortality rate. Acute massive PE combined with bilateral atrial thrombosis has an even higher mortality rate. PE treatments primarily include pharmaceuticals, catheter interventions, and surgical measures, with integrated treatment strategies demonstrating promising outcomes in clinical practice. Extracorporeal membrane oxygenation (ECMO) can provide cardiopulmonary support for the treatment of high-risk PE patients and is a proven therapeutic measure. Methods This report presents the case of a 52-year-old male admitted due to fever and sudden onset of impaired consciousness, with cardiac ultrasound and pulmonary artery CT angiography revealing an acute large-scale pulmonary embolism accompanied by bilateral atrial thrombosis, with the condition rapidly worsening and manifesting severe respiratory and circulatory failure. With ECMO support, the patient underwent a thrombectomy using an AngioJet intervention. The diagnosis of CAPS was confirmed through clinical presentation and laboratory examination, and treatment was adjusted accordingly. Results The patient made a successful recovery and was subsequently discharged from the hospital. Conclusion In CAPS patients, the rare instance of acute massive PE accompanied by bilateral atrial thrombosis significantly risks severe respiratory and circulatory failure, adversely affecting prognosis. Early initiation of ECMO therapy is crucial, offering a vital opportunity to address the root cause. In this case report the patient was successfully treated with an AngioJet thrombectomy supported by ECMO.
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Affiliation(s)
- Jianyu Ji
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Lei Jiang
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Research Center of Communicable and Severe Diseases, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Wei Wang
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Guangxi Health Commission Key Laboratory of Diagnosis and Treatment of Acute Respiratory Distress Syndrome, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Xinyu Chi
- Guangxi Health Commission Key Laboratory of Diagnosis and Treatment of Acute Respiratory Distress Syndrome, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Jinda Dong
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of Blood Transfusion, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Liqiu Lu
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Minyan Huang
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Xiutian Wei
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Guangbao Pang
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Jing Pang
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Bin Xiong
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Research Center of Communicable and Severe Diseases, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Shulin Xiang
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
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2
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Abdalla W, Almalki Y, Alkharoosi N, Basuoni A. 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. Cureus 2024; 16:e59536. [PMID: 38832194 PMCID: PMC11147166 DOI: 10.7759/cureus.59536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2024] [Indexed: 06/05/2024] Open
Abstract
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.
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Affiliation(s)
- Waleed Abdalla
- Cardiology, Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat, OMN
| | - Yasir Almalki
- Cardiology, Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat, OMN
| | - Noof Alkharoosi
- Cardiology, Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat, OMN
| | - Ahmed Basuoni
- Cardiology, Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat, OMN
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3
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Birrenkott DA, Kabrhel C, Dudzinski DM. Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies. Cardiol Clin 2024; 42:215-235. [PMID: 38631791 DOI: 10.1016/j.ccl.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.
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Affiliation(s)
- Drew A Birrenkott
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiac Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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4
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Watson NW, Weinberg I, Dicks AB, Carroll BJ, Secemsky EA. Clinical Outcomes and Predictors of Advanced Therapy for the Management of Right Heart Thrombus. Circ Cardiovasc Interv 2024; 17:e013637. [PMID: 38410989 PMCID: PMC11021139 DOI: 10.1161/circinterventions.123.013637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 01/26/2024] [Indexed: 02/28/2024]
Abstract
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.
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Affiliation(s)
- Nathan W. Watson
- Harvard Medical School, Boston, MA
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ido Weinberg
- Harvard Medical School, Boston, MA
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA
| | - Andrew B. Dicks
- Department of Vascular Surgery, Prisma Health/University of South Carolina School of Medicine – Greenville, Greenville, SC
| | - Brett J. Carroll
- Harvard Medical School, Boston, MA
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Eric A. Secemsky
- Harvard Medical School, Boston, MA
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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5
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Kobayashi T, Pugliese S, Sethi SS, Parikh SA, Goldberg J, Alkhafan F, Vitarello C, Rosenfield K, Lookstein R, Keeling B, Klein A, Gibson CM, Glassmoyer L, Khandhar S, Secemsky E, Giri J. Contemporary Management and Outcomes of Patients With High-Risk Pulmonary Embolism. J Am Coll Cardiol 2024; 83:35-43. [PMID: 38171708 DOI: 10.1016/j.jacc.2023.10.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Contemporary care patterns/outcomes in high-risk pulmonary embolism (PE) patients are unknown. OBJECTIVES This study sought to characterize the management of high-risk PE patients and identify factors associated with poor outcomes. METHODS A retrospective analysis of the PERT (Pulmonary Embolism Response Team) Consortium Registry was performed. Patients presenting with intermediate-risk PE, high-risk PE, and catastrophic PE (those with hemodynamic collapse) were identified. Patient characteristics were compared with chi-square testing for categorical covariates and Student's t-test for continuous covariates. Multivariable logistic regression was used to assess associations between clinical characteristics and outcomes in the high-risk population. RESULTS Of 5,790 registry patients, 2,976 presented with intermediate-risk PE and 1,442 with high-risk PE. High-risk PE patients were more frequently treated with advanced therapies than intermediate-risk PE patients (41.9% vs 30.2%; P < 0.001). In-hospital mortality (20.6% vs 3.7%; P < 0.001) and major bleeding (10.5% vs. 3.5%; P < 0.001) were more common in high-risk PE. Multivariable regression analysis demonstrated vasopressor use (OR: 4.56; 95% CI: 3.27-6.38; P < 0.01), extracorporeal membrane oxygenation use (OR: 2.86; 95% CI: 1.12-7.30; P = 0.03), identified clot-in-transit (OR: 2.26; 95% CI: 1.13-4.52; P = 0.02), and malignancy (OR: = 1.70; 95% CI: 1.13-2.56; P = 0.01) as factors associated with in-hospital mortality. Catastrophic PE patients (n = 197 [13.7% of high-risk PE patients]) had higher in-hospital mortality (42.1% vs 17.2%; P < 0.001) than those presenting with noncatastrophic high-risk PE. Extracorporeal membrane oxygenation (13.3% vs. 4.8% P < 0.001) and systemic thrombolysis (25% vs 11.3%; P < 0.001) were used more commonly in catastrophic PE. CONCLUSIONS In the largest analysis of high-risk PE patients to date, mortality rates were high with the worst outcomes among patients with hemodynamic collapse.
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Affiliation(s)
- Taisei Kobayashi
- Cardiovascular Medicine Division, Perelman School of Medicine. University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania, USA
| | - Steven Pugliese
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjum S Sethi
- Center for Interventional Cardiovascular Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Sahil A Parikh
- Center for Interventional Cardiovascular Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Joshua Goldberg
- Cardiothoracic Surgery Division, Westchester Medical Center, Westchester, New York, USA
| | - Fahad Alkhafan
- Boston Clinical Research Institute, Boston, Massachusetts, USA
| | - Clara Vitarello
- Boston Clinical Research Institute, Boston, Massachusetts, USA
| | - Kenneth Rosenfield
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert Lookstein
- Department of Radiology, Mount Sinai Medical Center, New York, New York, USA
| | - Brent Keeling
- Division of Cardiothoracic Surgery, Emory University Hospital, Atlanta, Georgia, USA
| | | | - C Michael Gibson
- Boston Clinical Research Institute, Boston, Massachusetts, USA; Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren Glassmoyer
- Cardiovascular Medicine Division, Perelman School of Medicine. University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sameer Khandhar
- Cardiovascular Medicine Division, Perelman School of Medicine. University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric Secemsky
- Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jay Giri
- Cardiovascular Medicine Division, Perelman School of Medicine. University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania, USA.
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6
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Malerba P, Laera N, Pagnesi M, Bonzi B, Rizzoni D, Metra M, Nardin M. Right ventricular thrombosis: from a case report to pathophysiology mechanisms and current treatment options. J Cardiovasc Med (Hagerstown) 2024; 25:88-94. [PMID: 38064342 DOI: 10.2459/jcm.0000000000001551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Paolo Malerba
- Division of Medicine, Department of Medicine, ASST Spedali Civili, Montichiari
- Department of Clinical and Experimental Sciences, University of Brescia
| | - Nicola Laera
- Department of Clinical and Experimental Sciences, University of Brescia
- Second Medicine Division, Department of Medicine, ASST Spedali Civili
| | | | - Bianca Bonzi
- Division of Medicine, Department of Medicine, ASST Spedali Civili, Montichiari
| | - Damiano Rizzoni
- Division of Medicine, Department of Medicine, ASST Spedali Civili, Montichiari
- Department of Clinical and Experimental Sciences, University of Brescia
| | - Marco Metra
- Division of Cardiology, ASST Spedali Civili
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia
| | - Matteo Nardin
- Department of Biomedical Sciences, Humanitas University, Milan
- Third Medicine Division, Department of Medicine, ASST Spedali Civili, Brescia, Italy
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7
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Brown B. Debulking the tricuspid valve with FlowTriever aspiration: A case series. Catheter Cardiovasc Interv 2023; 102:1282-1286. [PMID: 37855198 DOI: 10.1002/ccd.30888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/15/2023] [Accepted: 09/30/2023] [Indexed: 10/20/2023]
Abstract
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.
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Affiliation(s)
- Brian Brown
- Spartanburg Regional Health System, Spartanburg, South Carolina, USA
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8
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Feldman JM, Frishman WH, Aronow WS. Review of the Etiology, Diagnosis, Classification, and Therapy of Right Heart Thrombi. Cardiol Rev 2023:00045415-990000000-00176. [PMID: 37966248 DOI: 10.1097/crd.0000000000000630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Right heart thrombi are a rare phenomenon associated with high mortality rates and embolization to the pulmonary bed. Diagnostic modalities include transthoracic echocardiography, contrast-enhanced echocardiography, and cardiac magnetic resonance imaging. Several treatment options for right ventricular thrombus have been described in case reports and observational studies including anticoagulation, thrombolysis, catheter-based procedures, and surgical embolectomy. Various studies have demonstrated that thrombolysis and surgical embolectomy have better survival outcomes than anticoagulation alone. Present management strategies are supported by observational studies, and further research is needed to guide therapy.
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Affiliation(s)
- Jared M Feldman
- From the Division of Hospital Medicine, Long Island Jewish Medical Center and Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY
| | - William H Frishman
- Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, NY
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9
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Chirumamilla Y, Edupuganti S, Bachuwa G, Alkotob L. Right atrial thrombus leading to pulmonary embolism in a patient with dermatomyositis and COVID-19 managed with FlowTriever device thrombectomy. BMJ Case Rep 2023; 16:e255385. [PMID: 37945279 PMCID: PMC10649501 DOI: 10.1136/bcr-2023-255385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023] Open
Abstract
A woman in her late 40s presented with complaints of shortness of breath, right-sided pleuritic chest pain and diffuse myalgias. She was diagnosed with deep vein thrombosis (DVT) 3 weeks earlier and had been compliant with her oral anticoagulation therapy. Investigations revealed a pulmonary embolism (PE) involving the right distal pulmonary artery on a CT angiogram of the chest. She was also found to have an incidental SARS-CoV-2 (COVID-19) infection and an elevated creatine kinase value. Anticoagulation with intravenous heparin was initiated according to the DVT/PE protocol. The following morning, a medium-sized mobile mass was identified in her right atrium on performing a transthoracic echocardiogram. Due to concerns of embolisation of the mass which could result in obstruction, right ventricular strain and ultimately haemodynamic instability, a thrombectomy was performed using the FlowTriever device under transthoracic echocardiography guidance. The right atrial mass was successfully removed and the patient was transitioned to another oral anticoagulant agent. On discharge, a muscle biopsy was performed and aided in the diagnosis of dermatomyositis and the patient received intravenous Ig, steroids and methotrexate.
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Affiliation(s)
| | - Srujan Edupuganti
- Internal Medicine/Pediatrics, Hurley Medical Center, Flint, Michigan, USA
| | - Ghassan Bachuwa
- Internal Medicine, Hurley Medical Center, Flint, Michigan, USA
| | - Luay Alkotob
- Department of Cardiovascular Medicine, Hurley Medical Center, Flint, MI, USA
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10
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Watson NW, Weinberg I, Dicks AB, Fong E, Strom JB, Carroll BJ, Raja A, Schainfeld R, Secemsky EA. Clinical Significance of Right Heart Thrombus With and Without an Associated Pulmonary Embolism. Am J Med 2023; 136:1109-1118.e3. [PMID: 37572740 PMCID: PMC10592144 DOI: 10.1016/j.amjmed.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/14/2023]
Abstract
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.
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Affiliation(s)
- Nathan W Watson
- Harvard Medical School, Boston, Mass; Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Ido Weinberg
- Harvard Medical School, Boston, Mass; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Andrew B Dicks
- Harvard Medical School, Boston, Mass; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Esmond Fong
- Harvard Medical School, Boston, Mass; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Jordan B Strom
- Harvard Medical School, Boston, Mass; Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass; Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Brett J Carroll
- Harvard Medical School, Boston, Mass; Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass; Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Aishwarya Raja
- Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Robert Schainfeld
- Harvard Medical School, Boston, Mass; Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Eric A Secemsky
- Harvard Medical School, Boston, Mass; Smith Center for Outcomes Research in Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass; Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass.
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11
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Herron C, Batlivala SP, Shahanavaz S. Right atrial thrombus removal with use of the ŌNŌ retrieval device. Catheter Cardiovasc Interv 2023; 102:1105-1108. [PMID: 37855191 DOI: 10.1002/ccd.30877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/22/2023] [Accepted: 09/30/2023] [Indexed: 10/20/2023]
Abstract
Intracardiac masses and specifically right atrial thrombi can be difficult to manage and carry a high mortality rate. Typically, surgical removal or mechanical thrombectomy can be performed though may not be suitable for all patients. We present a unique case of a sickle cell patient with a large pedunculated right atrial thrombus that was successfully extracted using the novel ŌNŌ Retrieval Device.
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Affiliation(s)
- Christopher Herron
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sarosh P Batlivala
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Pediatric Cardiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Shabana Shahanavaz
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Division of Pediatric Cardiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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12
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Kim KW, Wheeler M, Schneider F, Carino G. Mechanical Thrombectomy for a Clot in Transit With Adherence to the Tricuspid Valve. Cureus 2023; 15:e46636. [PMID: 37936985 PMCID: PMC10627110 DOI: 10.7759/cureus.46636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2023] [Indexed: 11/09/2023] Open
Abstract
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.
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Affiliation(s)
- Kang Woo Kim
- Internal Medicine, Brown University, Providence, USA
| | - Mareril Wheeler
- Pulmonary and Critical Care, Brown University, Providence, USA
| | | | - Gerardo Carino
- Pulmonary and Critical Care, Brown University, Providence, USA
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13
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Daniels Z, Armstrong AK, Salavitabar A. First-in-paediatric uses of a mechanical aspiration system for percutaneous removal of right atrial masses. Cardiol Young 2023; 33:1730-1732. [PMID: 36924160 DOI: 10.1017/s1047951123000318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
We present the first-in-paediatric uses of a mechanical aspiration system for percutaneous removal of right atrial masses in three patients, including central line-related thrombus and metastatic tumour. Percutaneous mechanical removal of right atrial masses can be performed safely and effectively.
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Affiliation(s)
- Zachary Daniels
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
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14
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Nasser MF, Jabri A, Limaye S, Sharma S, Hamade H, Mhanna M, Aneja A, Gandhi S. Echocardiographic Evaluation of Pulmonary Embolism: A Review. J Am Soc Echocardiogr 2023; 36:906-912. [PMID: 37209948 DOI: 10.1016/j.echo.2023.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 05/22/2023]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death in the United States. Appropriate risk stratification is an important component of the initial evaluation for acute management of these patients. Echocardiography plays a crucial role in the risk stratification of patients with PE. In this literature review, we describe the current strategies in risk stratification of patients with PE using echocardiography and the role of echocardiography in the diagnosis of PE.
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Affiliation(s)
- Mohamed Farhan Nasser
- Heart and Vascular Center, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio
| | - Ahmad Jabri
- Heart and Vascular Center, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio
| | - Sneha Limaye
- Department of Medicine, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio
| | - Shorabh Sharma
- Department of Medicine, St. Barnabas Hospital Health System, New York, New York
| | - Hani Hamade
- Department of Medicine, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio
| | | | - Ashish Aneja
- Heart and Vascular Center, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio
| | - Sanjay Gandhi
- Heart and Vascular Center, Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio.
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15
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Bermudez M, Pedraza L, Guevara N, Erazo G, Valerio FR. Management of a Right Heart Intracavitary Thrombus in Transit in a Patient With Gastric Cancer in a Resource-Limited Setting: A Case Report. Cureus 2023; 15:e43133. [PMID: 37692570 PMCID: PMC10484470 DOI: 10.7759/cureus.43133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
A right atrial thrombus is an unusual source of imminent massive saddle pulmonary embolism (PE) . A hypercoagulable state secondary to gastric cancer (GC) can result in deep vein thrombosis (DVT) with a resultant right-sided heart thrombus in transit. Here, we present a case of a young male patient from Honduras with DVT and multiple venous thrombi extending from the external iliac veins to the suprahepatic left vein, inferior vena cava, and right atrium of the heart, secondary to a hypercoagulable state from GC, adenocarcinoma type. We describe the approach of treating a right heart intracavitary thrombus with imminent risk for saddle PE and sudden cardiac death with thrombolysis through a central venous catheter (CVC) in a resource-limited setting.
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Affiliation(s)
- Marco Bermudez
- Internal Medicine, St. Barnabas Hospital (SBH) Health System, Bronx, USA
| | - Laura Pedraza
- Internal Medicine, St. Barnabas Hospital (SBH) Health System, Bronx, USA
| | - Nehemias Guevara
- Internal Medicine, St. Barnabas Hospital (SBH) Health System, Bronx, USA
| | - Gloria Erazo
- Internal Medicine, Universidad Católica de Honduras, San Pedro Sula, HND
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16
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Hussain RN, Mandal AKJ, Li N, Kafsi JE, Sioftanos A, Missouris CG. Right heart thrombus in transit and peripherally inserted central catheters. Thromb J 2023; 21:68. [PMID: 37349797 DOI: 10.1186/s12959-023-00513-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/11/2023] [Indexed: 06/24/2023] Open
Abstract
Right heart thrombus in transit or "free-floating right heart thrombus" is defined as thrombus(i) arising from the deep veins that embolises to the right atrium or right ventricle before reaching the pulmonary vasculature. It is almost always associated with pulmonary thromboembolism and is a medical emergency with reported mortality rates of over 40%. We present two cases of right heart thrombus in transit with pulmonary thromboembolism resulting from venous thrombosis associated with peripherally inserted central catheters that were managed with different approaches. The cases highlight that clinicians should have a low threshold to utilise imaging modalities such as computerised tomography and transthoracic echocardiography when there is an untoward change in physiological parameters among patients with peripherally inserted central catheters, particularly those with risk factors for peripherally inserted central catheter associated venous thrombosis. Furthermore, procedural optimisation surrounding peripherally inserted central catheters, such as insertion technique and choice of lumen size, is underscored.
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Affiliation(s)
- Rezwan N Hussain
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | - Amit K J Mandal
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK.
| | - Nick Li
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
- The Queen's College, University of Oxford, Oxford, UK
| | - Jihène El Kafsi
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
- Ashford and St Peter's NHS Foundation Trust, Chertsey, UK
| | | | - Constantinos G Missouris
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
- University of Nicosia Medical School, Nicosia, Cyprus
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17
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Khan WJ, Asif M, Nadeem I, Moeding M, Baab T, Chowdhury M. Management and Follow-Up of Biventricular Thrombi. Cureus 2023; 15:e39269. [PMID: 37342748 PMCID: PMC10279459 DOI: 10.7759/cureus.39269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2023] [Indexed: 06/23/2023] Open
Abstract
A thrombus is the most common intracardiac lesion. Isolated thrombi usually occur in the setting of ventricular dysfunction, such as a dyskinetic or hypokinetic myocardial wall, following an acute myocardial infarction (MI) or in cardiomyopathies (CM). Concurrent biventricular thrombus formation is rare. There are no clear guidelines for the treatment of biventricular thrombus. In this report, we describe our experience of the successful treatment of a case of biventricular thrombus with warfarin and rivaroxaban.
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Affiliation(s)
- Wahab J Khan
- Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, USA
| | - Muhammad Asif
- Internal Medicine, Avera McKennan Hospital and University Health Center, Sioux Falls, USA
| | - Ifrah Nadeem
- Internal Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, USA
| | - Megan Moeding
- Cardiovascular Medicine, North Central Heart Institute, Sioux Falls, USA
| | - Thomas Baab
- Cardiovascular Medicine, North Central Heart Institute, Sioux Falls, USA
| | - Mohammed Chowdhury
- Cardiovascular Medicine, North Central Heart Institute, Sioux Falls, USA
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18
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Tateishi K, De Gregorio J. Thrombectomy of right atrial thrombus for an elderly patient. Cardiovasc Interv Ther 2023; 38:260-261. [PMID: 36602634 DOI: 10.1007/s12928-023-00910-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/02/2023] [Indexed: 01/06/2023]
Affiliation(s)
- Kazuya Tateishi
- Cardiovascular Services, Englewood Health, 350 Engle Street, Englewood, NJ, 07631, USA.
| | - Joseph De Gregorio
- Cardiovascular Services, Englewood Health, 350 Engle Street, Englewood, NJ, 07631, USA
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19
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Bajwa A, Farooqui SM, Hussain ST, Vandyck K. Right heart thrombus in transit: Raising bar in the management of cardiac arrest. Respir Med Case Rep 2022; 41:101801. [PMID: 36618850 PMCID: PMC9817167 DOI: 10.1016/j.rmcr.2022.101801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/07/2022] [Accepted: 12/18/2022] [Indexed: 12/31/2022] Open
Abstract
Right heart thrombus represents medical emergency as it is associated with acute pulmonary embolism. Right heart thrombus can manifest acutely in a dramatic fashion as cardiac arrest. Bedside echocardiography is a key to rapid diagnosis and allow early intervention. We report a case of elderly female who was admitted to our hospital after a mechanical fall and found to have hip fracture. Despite an initial uncomplicated course, she experienced cardiopulmonary arrest with right heart clot in transit identified on transesophageal echocardiography (TEE). We highlight the utility of point-of-care ultrasound as well as use of TEE to establish cause of cardiopulmonary arrest.
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Affiliation(s)
- Awais Bajwa
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
- Corresponding author. Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd. AAT 6300, Oklahoma City, OK, 73104, USA.
| | - Samid M. Farooqui
- Section of Pulmonary, Critical Care, and Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
| | - Syed T. Hussain
- Section of Pulmonary, Critical Care, and Sleep Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
| | - Kofi Vandyck
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, USA
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20
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Li LT, Alexis M, Wilson SR, Yu PJ. Suction-based catheter retrieval of right ventricular clot-in-transit. Catheter Cardiovasc Interv 2022; 101:478-480. [PMID: 36573416 DOI: 10.1002/ccd.30533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/06/2022] [Accepted: 12/16/2022] [Indexed: 12/28/2022]
Abstract
Right ventricular clot-in-transit (CIT) is a rare finding in venous thromboembolic disease and carries a high mortality rate. Its optimal treatments have yet to be established in the literature. Here we describe the usage of a suction-based catheter, the INARI FlowTriever® system (INARI Medical Inc.) to successfully retrieve a CIT from the right ventricle of a patient with coronavirus disease 2019 acute respiratory distress syndrome on veno-veno extracorporeal membrane oxygenation.
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Affiliation(s)
- Leo T Li
- Northwell Health, North Shore/Long Island Jewish General Surgery, Manhasset, New York, USA
| | - Miguel Alexis
- Division of Cardiovascular and Thoracic Surgery, Northwell Health, North Shore University Hospital, New York, Manhasset, USA
| | - Sean R Wilson
- Department of Cardiology, North Shore University Hospital, Manhasset, New York, USA
| | - Pey-Jen Yu
- Division of Cardiovascular and Thoracic Surgery, Northwell Health, North Shore University Hospital, New York, Manhasset, USA
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21
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Wang H, Zi J, Li Q, Sun Y, Zhu L. Case report: A rare case of recurrent right atrial mass dramatically disappeared after anticoagulation. Front Cardiovasc Med 2022; 9:1066065. [DOI: 10.3389/fcvm.2022.1066065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022] Open
Abstract
A young man repeatedly found a right atrial mass with severe wheezing and extreme dyspnea. His condition was critical and complicated. The process of correct diagnosis was full of twists and turns. Finally, he got better and was discharged from the hospital after anticoagulation therapy, which suggested that correct clinical thinking and decision are particularly important in the process of diagnosis and treatment.
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22
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Mathevosian S, Ranade M. Right Heart Clot-in-Transit: Endovascular Therapies. Semin Intervent Radiol 2022; 39:515-522. [PMID: 36561934 PMCID: PMC9767789 DOI: 10.1055/s-0042-1757942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Right heart thrombus is a challenging high mortality disease typically seen in the setting of pulmonary embolism. Traditional treatments have included anticoagulation, thrombolysis, and surgical embolectomy. Advances in recognition and treatment of clot-in-transit have led to the development of endovascular therapies increasingly becoming the preferred method of treatment due to rapid debulking and lower morbidity. Novel endovascular devices are large bore aspiration thrombectomy systems which mitigate the use of concomitant thrombolytics. The article reviews the disease process, relevant literature, and current endovascular devices and strategies for the treatment of right heart thrombus and clot-in-transit.
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Affiliation(s)
- Sipan Mathevosian
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Mona Ranade
- Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California
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23
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Documentation of Deep Vein Thrombosis Should Be a Requirement for Reporting Embolus in Transit. J Emerg Med 2022; 63:597-598. [DOI: 10.1016/j.jemermed.2022.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/12/2022] [Accepted: 06/04/2022] [Indexed: 12/05/2022]
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24
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Kochar A, Bergmark BA. Catheter-directed interventions for pulmonary embolism. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:721-727. [PMID: 35905304 DOI: 10.1093/ehjacc/zuac089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 06/15/2023]
Abstract
Pulmonary embolism (PE) is common, life-threatening, and often recurrent among survivors. The clinical manifestations of PE range from incidental detection to sudden death, with approximately one-third of PE deaths occurring suddenly. State-of-the-art management of acute PE relies on early detection, risk stratification based on clinical, imaging, and biomarker criteria, and multidisciplinary decision-making. The primary goal of catheter-directed interventions for acute PE is to interrupt the cycle of right ventricular failure, hypoperfusion, and oxygen supply/demand imbalance by increasing the cross-sectional area of the patent pulmonary vasculature, thereby lowering resistance and alleviating V/Q mismatch. Innovations in percutaneous interventions have led to several approaches described in this review: rheolytic thrombectomy, catheter-directed thrombolysis, and aspiration or mechanical thrombectomy. The central challenge moving forward will be integrating growing clinical trial evidence into multidisciplinary, individualized care pathways meeting the diverse clinical needs of patients presenting with acute PE.
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Affiliation(s)
- Ajar Kochar
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Brian A Bergmark
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Hale Building for Transformative Medicine, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
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25
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Right Ventricular Thrombus in Transit or Just a Right Heart Thrombus? Eppur si Muove! J Emerg Med 2022; 63:458-459. [DOI: 10.1016/j.jemermed.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 07/10/2022] [Indexed: 11/13/2022]
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26
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Chopard R, Behr J, Vidoni C, Ecarnot F, Meneveau N. An Update on the Management of Acute High-Risk Pulmonary Embolism. J Clin Med 2022; 11:jcm11164807. [PMID: 36013046 PMCID: PMC9409943 DOI: 10.3390/jcm11164807] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 11/16/2022] Open
Abstract
Hemodynamic instability and right ventricular (RV) dysfunction are the key determinants of short-term prognosis in patients with acute pulmonary embolism (PE). High-risk PE encompasses a wide spectrum of clinical situations from sustained hypotension to cardiac arrest. Early recognition and treatment tailored to each individual are crucial. Systemic fibrinolysis is the first-line pulmonary reperfusion therapy to rapidly reverse RV overload and hemodynamic collapse, at the cost of a significant rate of bleeding. Catheter-directed pharmacological and mechanical techniques ensure swift recovery of echocardiographic parameters and may possess a better safety profile than systemic thrombolysis. Further clinical studies are mandatory to clarify which pulmonary reperfusion strategy may improve early clinical outcomes and fill existing gaps in the evidence.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
- F-CRIN, INNOVTE Network, 42055 Saint-Etienne, France
- Correspondence:
| | - Julien Behr
- Department of Radiology, University Hospital Besançon, 25000 Besancon, France
| | - Charles Vidoni
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
- F-CRIN, INNOVTE Network, 42055 Saint-Etienne, France
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27
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Lane CM, Young KA, Norton MS, Bennett CE, Anavekar NS. Right Heart Thrombus in Transit on Point-of-Care Ultrasound: A Rare Finding with Key Management Repercussions. CASE 2022; 6:239-242. [PMID: 36036053 PMCID: PMC9399530 DOI: 10.1016/j.case.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Right heart thrombi are associated with high early mortality in PE. POCUS allows rapid assessment in hemodynamic compromise and suspected PE. Triple POCUS assessment of the lung, heart, and leg veins may improve PE detection.
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Affiliation(s)
- Conor M. Lane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Kathleen A. Young
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark S. Norton
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Nandan S. Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
- Correspondence: Nandan S. Anavekar, MB, BCh, Mayo Clinic, 200 First Street SW, Rochester, MN 55905
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28
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Achuthanandan S, Harris CL, Farooqui AA, Hollander G. Right Ventricular Thrombus Masquerading as a Tumor. Cureus 2022; 14:e26014. [PMID: 35720779 PMCID: PMC9203128 DOI: 10.7759/cureus.26014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 12/02/2022] Open
Abstract
Cardiac tumors are an uncommon phenomenon. Although they can be cardiac in origin, most represent a distant neoplastic growth metastasizing to the heart. Cardiac tumors can be benign or malignant. They may be symptomatic or, more commonly, found incidentally. Clinical presentation is typically related to that of dispersed neoplasm. We report a case of a 36-year-old young man with an unusually large and smooth-surfaced right ventricular mass. The patient presented to the emergency department with exertional dyspnea for two weeks. Past medical history was significant for deep venous thrombosis with non-adherence to anti-coagulation. Computerized tomographic (CT) angiography showed bilateral pulmonary emboli and a hypodense opacity in the right ventricle. A transthoracic echocardiogram showed a right ventricular non-mobile mass. The patient underwent surgical removal of the mass, which pathology demonstrated to be a thrombus. Cardiac masses can be difficult to differentiate based on imaging alone. Physicians should maintain a high index of suspicion for intracardiac thrombi as early identification and prompt treatment are imperative in improving patient outcomes.
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29
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Pai PG, Hegde NN, Shah S. Thrombus-in-transit involving all four chambers of the heart in a patient presenting with acute pulmonary embolism. J Cardiol Cases 2022; 26:186-189. [DOI: 10.1016/j.jccase.2022.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/14/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
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30
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Khosla A, Mojibian H, Assi R, Tantawy H, Singh I, Pollak J. Right heart thrombi (RHT) and clot in transit with concomitant PE management: Approach and considerations. Pulm Circ 2022; 12:e12080. [PMID: 35514771 PMCID: PMC9063956 DOI: 10.1002/pul2.12080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/04/2022] [Accepted: 04/06/2022] [Indexed: 11/06/2022] Open
Abstract
Right heart thrombi (RHT) continues to pose a clinical dilemma for multiple specialties and is especially concerning when present with concomitant pulmonary embolism (PE). Patients with PE and RHT are at an increased risk of poor outcomes compared to PE without RHT. Although the exact incidence of RHT is unknown, the increasing use of point-of-care ultrasound may lead to an increased detection and frequency of RHT. There are multiple treatment strategies available for RHT, including anticoagulation, systemic thrombolysis, and endovascular and surgical therapies. Given that these treatment strategies involve multiple medical specialties, the management of RHT with concomitant PE can be complex. Currently, there is limited clinical data and guidelines on the treatment and management of RHT. We aim to provide a review on RHT with concomitant PE, including risk stratification, treatment considerations, and our approach to the management of RHT.
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Affiliation(s)
- Akhil Khosla
- Department of Internal Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of MedicineYale New Haven HospitalNew‐HavenConnecticutUSA
| | - Hamid Mojibian
- Department of Radiology and Biomedical Imaging, Section of Vascular and Interventional RadiologyYale University School of MedicineNew HavenConnecticutUSA
| | - Roland Assi
- Division of Cardiac SurgeryYale University School of MedicineNew HavenConnecticutUSA
| | - Hossam Tantawy
- Department of AnesthesiologyYale University School of MedicineNew HavenConnecticutUSA
| | - Inderjit Singh
- Department of Internal Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of MedicineYale New Haven HospitalNew‐HavenConnecticutUSA
| | - Jeffrey Pollak
- Department of Radiology and Biomedical Imaging, Section of Vascular and Interventional RadiologyYale University School of MedicineNew HavenConnecticutUSA
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31
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Raghupathy S, Barigidad AP, Doorgen R, Adak S, Malik RR, Parulekar G, Patel JJ, Lanka SP, Varghese GM, Rashid M, Patel U, Patel A, Hsieh YC. Prevalence, Trends, and Outcomes of Pulmonary Embolism Treated with Mechanical and Surgical Thrombectomy from a Nationwide Inpatient Sample. Clin Pract 2022; 12:204-214. [PMID: 35314594 PMCID: PMC8938787 DOI: 10.3390/clinpract12020024] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 02/16/2022] [Accepted: 03/07/2022] [Indexed: 02/04/2023] Open
Abstract
Pulmonary embolism (PE) is the third most common vascular disease in the US, a frequently underdiagnosed and potentially fatal condition where embolic material blocks one or more pulmonary arteries impairing blood flow. In this study, we aim to describe the prevalence, outcomes, and predictors of mortality of PE patients treated with mechanical (MT) and surgical thrombectomy (ST). This is a retrospective study using the Agency for Healthcare Research and Quality’s HCUP NIS data from 2010−2018. We used the ninth and tenth revisions of the International Classification of Diseases clinical modification codes (ICD-9-CM and ICD-10-CM) to identify patients admitted with a primary diagnosis of PE (ICD-10-CM codes I26.02, I26.09, I26.92, I26.93, I26.94, and I26.99; ICD-9-CM codes 415.11, 415.13, and 415.19). We extracted demographics, hospital-level, and patient-level characteristics, and defined the severity of comorbid conditions using Deyo modification of the Elixhauser Comorbidity Index. The primary outcomes of interest were the utilization trends of PE (treated with MT and ST); the secondary outcomes were mortality, discharge to facility, peri-procedural complications, and length of hospital (LOS) stay; the tertiary outcome was to identify the predictors of in-hospital mortality. From 2010−2018, there were 1,627,718 hospitalizations for PE, of which 6531 (0.39%) underwent MT and 3465 (0.21%) underwent ST. The utilization trend of MT increased from 336 (0.20%) in 2010 to 1655 (0.87%) in 2018; the utilization trend of ST was 260 (0.15%) in 2010 and 430 (0.23%) in 2018. The unadjusted in-hospital mortality for MT was 9.1% with the mean LOS being 7(±0.3) days; for ST, mortality was 13.9% with a mean LOS of 13(±0.4) days. The occurrences of periprocedural complications for MT and ST were as follows: invasive mechanical ventilation was 13.8% and 32%; cardiopulmonary bypass was 3.3% and 68.3%; pulmonary embolectomy surgery was 1.7%; and bleeding complications were 1.4% and 3.4%. Predictors associated with in-hospital mortality for MT were: increasing age (OR 1.2, 95% CI 1.0−1.3, p < 0.026), female sex (OR 1.9, 95% CI 1.2−2.8, p < 0.004), large hospitals (OR 2.2, 95% 1.4−3.5, p < 0.001), and teaching hospitals (OR 1.8, 95% CI 1.1−3.1, p < 0.023). The predictor of in-hospital mortality for ST was increasing age (OR 1.2, 95% CI 1.0−1.4, p < 0.046). The number of MT procedures performed has rapidly increased over the past decade. Further studies are warranted to determine their rise and therapeutic use.
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Affiliation(s)
- Shalini Raghupathy
- Department of Surgery, K.A.P. Vishwanadham Government Medical College, Trichy 620001, Tamil Nadu, India;
| | - Achala Prashant Barigidad
- Department of Surgery, Bangalore Medical College and Research Institute, Bengaluru 560002, Karnataka, India;
| | - Raydiene Doorgen
- Department of Surgery, American University of Antigua, St. John’s P.O. Box W1451, Coolidge, Antigua and Barbuda;
| | - Shrestha Adak
- Department of Surgery, Kolkata Medical College and Hospital, Kolkata 700073, West Bengal, India;
| | - Rohma Rafique Malik
- Department of Anesthesia, Ras Al Khaimah College of Medical Sciences, Ras Al Khaimah P.O. Box 11172, United Arab Emirates;
| | - Gaurav Parulekar
- Department of Biology, York University, Toronto, ON M3J 1P3, Canada;
| | - Jeet Janak Patel
- Department of Surgery, B.J. Medical College, Ahmedabad 380016, Gujarat, India;
| | - Santh Prakash Lanka
- Department of Surgery, Rangaraya Medical College, Kakinada 533001, Andhra Pradesh, India;
| | | | - Mohammed Rashid
- Department of General Surgery, University of Illinois Metropolitan Group Hospitals, Chicago, IL 60657, USA;
| | - Urvish Patel
- Department of Public Health, Icahn School of Medicine Mount Sinai, New York, NY 10029, USA; (U.P.); (A.P.)
| | - Achint Patel
- Department of Public Health, Icahn School of Medicine Mount Sinai, New York, NY 10029, USA; (U.P.); (A.P.)
| | - Ya-Ching Hsieh
- Department of Public Health, Icahn School of Medicine Mount Sinai, New York, NY 10029, USA; (U.P.); (A.P.)
- Correspondence:
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32
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Moriarty JM, Liao M, Kim GHJ, Yang E, Desai K, Ranade M, Plotnik AN. Procedural outcomes associated with use of the AngioVac System for right heart thrombi: A safety report from RAPID registry data. Vasc Med 2022; 27:277-282. [PMID: 35176918 DOI: 10.1177/1358863x211073974] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Right heart thrombi can be a source of considerable morbidity and mortality, especially when associated with pulmonary embolism. Methods: To understand the safety and procedural efficacy associated with vacuum-assisted thrombectomy using the AngioVac System (AngioDynamics, Latham, NY, USA) to remove right heart thrombi, we conducted a subanalysis of the Registry of AngioVac Procedures in Detail (RAPID) multicenter registry representing 47 (20.1%) of 234 participants in the registry. Forty-two (89.4%) patients had thrombi located in the right atrium alone, three (6.4%) in the right ventricle alone, and two (4.3%) in both the right atrium and ventricle. Four (8.5%) patients had concomitant caval thrombi, three (6.4%) also had catheter-related thrombi, and one (2.1%) patient had both caval and catheter-related thrombi with their right heart thrombi. Results: Extracorporeal bypass time was less than 1 hour for 39 (83.0%) procedures. Seventy to 100% removal of thrombus was achieved in 59.6% of patients. Estimated blood loss was less than 250 cc for 43 procedures (91.6%). Mean hemoglobin decreased from 10.7 ± 2.2 g/dL preoperatively to 9.6 ± 1.6 g/dL postoperatively. Transfusions were administered for eight procedures (17.0%), with only one (2.1%) patient receiving more than 2 units of blood. Six patients (12.8%) experienced procedure-related adverse events, including three (6.4%) patients who experienced distal emboli and three (6.4%) patients who developed bleeding-related complications. All adverse events resolved prior to discharge. There was one death (2.1%) reported that was not procedure related. Conclusion: Vacuum-assisted thrombectomy can be performed safely in patients with right heart thrombi. ClinicalTrials.gov Identifier: NCT04414332.
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Affiliation(s)
- John M Moriarty
- Department of Radiology, Division of Interventional Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Millie Liao
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Grace Hyun J Kim
- Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Department of Medicine, Division of Cardiology, UCLA Medical Center, Los Angeles, CA, USA
| | - Eric Yang
- Department of Medicine, Division of Cardiology, UCLA Medical Center, Los Angeles, CA, USA
| | - Kush Desai
- Department of Radiology, Division of Interventional Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Mona Ranade
- Department of Radiology, Division of Interventional Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Adam N Plotnik
- Department of Radiology, Division of Interventional Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Ibrahim WH, Ata F, Choudry H, Javed H, Shunnar KM, Shams A, Arshad A, Bosom A, Elkahlout MH, Sawaf B, Ahmed SM, Olajide T. Prevalence, Outcome, and Optimal Management of Free-Floating Right Heart Thrombi in the Context of Pulmonary Embolism, a Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2022; 28:10760296221140114. [PMID: 36384306 PMCID: PMC9677292 DOI: 10.1177/10760296221140114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Free-floating right-heart thrombus (FFRHT) in the context of a pulmonary embolism (PE) is a rare but serious encounter with no guidelines addressing its management. We performed a systematic review and meta-analysis addressing prevalence, clinical behavior, and outcomes of FFRHT associated with PE. Among the included 397 patients with FFRHT and PE, dyspnea was the main presenting symptom (73.3%). Obstructive shock was documented in 48.9% of cases. Treatment with thrombolytic therapy, surgical thrombectomy, and percutaneous thrombectomy was documented in 43.8%, 32.7%, and 6.5% of patients, respectively. The overall mortality rate was 20.4%. Syncope ( p: 0.027), chest pain ( p: 0.006), and obstructive shock ( p: 0.037) were significantly associated with mortality. Use of thrombolytic therapy was significantly associated with survival ( p: 0.008). A multivariate logistic regression model to determine mortality predictors revealed that syncope (OR: 1.97, 95% CI: 1.06–3.65, p: 0.03), and obstructive shock (OR: 2.23, 95% CI: 1.20–4.14, p: 0.01) were associated with increased death odds. Treatment with thrombolytic therapy (OR: 0.22, 95% CI: 0.086–0.57, p: 0.002) or surgical thrombectomy (OR: 0.35, 95% CI: 0.137–0.9, p: 0.03) were associated with reduced death odds. Meta-analysis of observational studies revealed a pooled prevalence of FFRHT among all PE cases of 8.1%, and overall mortality of 23%. Although uncommon, the presence of FFRHT in the context of PE is associated with high obstructive shock and mortality rates. Favorable survival odds are observed with thrombolytic therapy and surgical thrombectomy. Data are derived from case reports and observational studies. Clinical trials elucidating these findings are needed.
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Affiliation(s)
- Wanis H. Ibrahim
- Department of Pulmonology and Internal Medicine, Weill-Cornell Medicine & Hamad General Hospital, Doha, Qatar
| | - Fateen Ata
- Department of Internal Medicine, Hamad General Hospital, Doha, Qatar
| | - Hassan Choudry
- Department of Respiratory Medicine, University Hospital of Leicester, Leicester, UK
| | - Huzaifa Javed
- Department of Medicine, Cavan General Hospital, Cavan, Ireland
| | - Khaled M Shunnar
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abdullah Shams
- Department of Internal Medicine, Hamad General Hospital, Doha, Qatar
| | - Abdullah Arshad
- Department of Internal Medicine, Hamad General Hospital, Doha, Qatar
| | - Adel Bosom
- Department of Internal Medicine, Hamad General Hospital, Doha, Qatar
| | | | - Bisher Sawaf
- Department of Internal Medicine, Hamad General Hospital, Doha, Qatar
| | - Shahda M.A. Ahmed
- Department of Internal Medicine, Hamad General Hospital, Doha, Qatar
| | - Tinuola Olajide
- Department of Internal Medicine, Hamad General Hospital, Doha, Qatar
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34
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Stombaugh DK, Daubenspeck D, Chaney MA, Lu S, Fitzsimons MG, Gerlach RM. Percutaneous Vacuum-Assisted Thrombectomy for Right Atrial Mass. J Cardiothorac Vasc Anesth 2021; 36:3392-3402. [DOI: 10.1053/j.jvca.2021.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 12/12/2021] [Indexed: 11/11/2022]
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35
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Yu T, Yang EH, Ranade M. AngioVac aspiration of right atrial cardiac pacemaker lead-associated thrombus with concurrent PE under fluoroscopic and transesophageal echocardiographic guidance: a multidisciplinary collaboration for improved patient outcome. Clin Imaging 2021; 81:33-36. [PMID: 34598001 DOI: 10.1016/j.clinimag.2021.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/21/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022]
Abstract
In the U.S., pulmonary embolism (PE) is a common cause of cardiovascular death. Right heart thrombus (RHT) occurs in approximately 4% of patients with PE, and when concurrent is associated with increased 30-day PE-related and all-cause mortality. The consensus on optimal management of acute massive or high-risk PE is unclear, and even less so for concurrent RHT. In this report, we review a successful multidisciplinary coordination of vacuum-assisted thrombectomy (VAT) of a complex pacemaker lead-associated RHT in a patient with concurrent acute PE and significant comorbidities, using the AngioVac system (Vortex Medical, Norwell, MA). VAT is a reasonable treatment option that should be considered particularly for patients who are poor surgical or thrombolytic candidates. Procedural success and patient outcomes can be further optimized through multidisciplinary collaboration such as with the Pulmonary Embolism Response Team (PERT) model.
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Affiliation(s)
- Tiffany Yu
- Department of Radiological Sciences, University of California at Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, United States of America.
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, United States of America.
| | - Mona Ranade
- Department of Radiological Sciences, University of California at Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, United States of America.
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36
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Callese TE, Yang EH, Levi D, Srinivasa RN, Moriarty JM. Concomitant AngioVac thrombectomy and patent foramen ovale closure in a patient with a large right atrial thrombus and recent paradoxical embolic stroke. ACTA ACUST UNITED AC 2021; 27:272-274. [PMID: 33599209 DOI: 10.5152/dir.2021.20291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A 59-year-old male with a history of gallbladder adenocarcinoma receiving chemotherapy and on therapeutic anticoagulation for portal vein thrombosis presented to the emergency department via ambulance after being found unresponsive and in cardiac arrest. Initial workup upon return of spontaneous circulation revealed a large right atrial mass, patent foramen ovale (PFO), and bilateral acute cortical infarctions. This constellation of findings were concerning for PFO-related paradoxical embolic strokes. Given the risk of recurrent paradoxical embolic events and the absolute contraindication to thrombolysis due to recent cerebral infarction, the decision was made to proceed with percutaneous vacuum-assisted thrombectomy using the AngioVac device. To prevent intraoperative thrombus propagation, PFO-closure was performed immediately prior to thrombectomy. Aspiration thrombectomy and PFO-closure were successful with complete thrombus removal and no intraoperative thrombus propagation. This case presents a minimally invasive and rapid treatment for a complex problem. An efficient and effective interdisciplinary team-based approach allowed the patient to resume cancer treatment relatively unabated.
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Affiliation(s)
- Tyler E Callese
- Division of Interventional Radiology, Department of Radiology, University of California, Los Angeles, California, USA
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California, Los Angeles, California, USA
| | - Daniel Levi
- Division of Pediatric Cardiology, Department of Pediatrics, University of California, Los Angeles, California, USA
| | - Ravi N Srinivasa
- Division of Interventional Radiology, Department of Radiology, University of California, Los Angeles, California, USA
| | - John M Moriarty
- Division of Interventional Radiology, Department of Radiology, University of California, Los Angeles, California, USA
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37
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Abohamr SI, Abdulrahim AE, Hussein NM, Elsheikh E, ALhindi DA, Saadeddin HM, Abazid RM. Multimodality imaging in COVID19 patient with large mobile RV thrombus protruding into the pulmonary trunk with bilateral pulmonary embolism. J Cardiol Cases 2021; 24:215-217. [PMID: 34518773 PMCID: PMC8426289 DOI: 10.1016/j.jccase.2021.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/08/2021] [Accepted: 08/17/2021] [Indexed: 11/26/2022] Open
Abstract
Inflammation related to coronavirus disease (COVID)-19 can promote a pro-thrombotic process and subsequent thrombosis. We report a confirmed COVID-19 case in a 51-year-old patient who presented with chest pain and severe hypoxemia. Although the right heart chambers are unusual locations for a thrombus, an echocardiogram demonstrated a large mobile right ventricular thrombus protruding into the right ventricle outflow tract. A computed tomography angiogram and cardiac magnetic resonance image showed the extension of the thrombus into the pulmonary trunk. A continuous intravenous unfractionated heparin infusion resulted in a dramatic clinical and echocardiographic improvement. <Learning objective: With COVID-19 infection, the thrombus phenomenon is becoming more common. Since thromboembolic complications are common in patients with severe COVID-19 who need intensive care unit care, heparin infusion is recommended for patients who are unlikely to need procedures. Multimodality imaging can be useful in determining the diagnosis, prognosis, and treatment plan.>.
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Affiliation(s)
- Samah I Abohamr
- Department of Cardiology, Faculty of Medicine, Tanta University Hospital, Tanta, Egypt.,Heart Health Center, King Saud Medical City, Riyadh, Saudi Arabia
| | | | - Nada M Hussein
- Heart Health Center, King Saud Medical City, Riyadh, Saudi Arabia
| | - Eman Elsheikh
- Department of Cardiology, Faculty of Medicine, Tanta University Hospital, Tanta, Egypt.,Internal Medicine Department, King Faisal University, Alahsa, Saudi Arabia
| | - Duaa A ALhindi
- Radiology Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Hiba M Saadeddin
- Heart Health Center, King Saud Medical City, Riyadh, Saudi Arabia
| | - Rami M Abazid
- Division of Nuclear Medicine, Section of Cardiac Hybrid Imaging, Victoria Hospital, London Health Sciences Centre, London, Ontario, Canada.,Prince Sultan Cardiac Center Qassim (PSCCQ), Buraydah, Al-Qassim, Saudi Arabia
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38
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Callese TE, O'Brien DP, Wilhalme H, Yang EH, Moriarty JM. AngioVac Aspiration Thrombectomy of Right Atrial Thrombus is Safe and Effective in Cancer Patients. Ann Vasc Surg 2021; 77:243-254. [PMID: 34437971 DOI: 10.1016/j.avsg.2021.05.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 05/16/2021] [Accepted: 05/24/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aim of this study was to test the hypothesis that endovascular aspiration thrombectomy of right atrial thrombus (RAT) using the AngioVac device is as safe and effective in patients with cancer as those without cancer. BACKGROUND RAT is a uniquely challenging clinical presentation of venous thromboembolism due to its low incidence and historically high-risk of mortality due to thrombus propagation into the pulmonary arteries. There is a lack of consensus regarding management, particularly in high-risk cancer patients. Endovascular aspiration thrombectomy utilizing the AngioVac device is effective in removal of right atrial thrombus and may be a safer option for patients with cancer in whom avoidance of higher-risk intervention is preferred. METHODS This was an institutional review board-approved retrospective single-center case control study of patients with RAT who underwent AngioVac aspiration thrombectomy between August 2013 and July 2020. Analysis of patient demographics and clinical characteristics, thrombus-related factors, and operative details was performed. Primary endpoints included survival, safety, and technical success. RESULTS A total of 44 patients met inclusion criteria, 20 of whom with active malignancy. The oncology group had a significantly higher Charlson comorbidity index (P = 0.01). Comparative outcomes between the oncology and non-oncology group showed no difference in survival (P = 0.8) or technical success (OR 3, 95% CI 0.83-10.9). There were 9 complications, including 6 minor, 1 moderate, 1 severe, and 1 death. CONCLUSIONS AngioVac aspiration thrombectomy of RAT is as safe and effective in patients with cancer as those without cancer.
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Affiliation(s)
- Tyler E Callese
- Department of Radiology, Division of Interventional Radiology, University of California at Los Angeles, Los Angeles, CA.
| | - Daniel P O'Brien
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA
| | - Holly Wilhalme
- Department of Medicine, Division of General Internal Medicine and Health Services Research, Los Angeles, CA
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA
| | - John M Moriarty
- Department of Radiology, Division of Interventional Radiology, University of California at Los Angeles, Los Angeles, CA
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39
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Verma I, Chang EY, Kumar G, Sachdeva R. Catheter directed embolectomy of right atrial clot in transit-A case series. Catheter Cardiovasc Interv 2021; 97:869-873. [PMID: 33226187 DOI: 10.1002/ccd.29391] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/12/2020] [Accepted: 11/09/2020] [Indexed: 11/08/2022]
Abstract
In the previous literature, the prevalence of right atrial (RA) clot-in-transit associated with pulmonary embolism is around 4-18% with an associated mortality of 80-100% in untreated cases. Surgical thrombo-embolectomy has been the mainstay of treatment for stable patients but the data for percutaneous thrombo-embolectomy is lacking in the literature. We present a series of three cases of right atrium clot-in-transit treated with catheter-based therapies with Inari FlowTriever® (Inari Medical, Irvine, CA). Our three patients had different clinical profiles and presentations of right atrial clot-in-transit. All of the subjects had contraindications to surgical thrombo-embolectomy and thrombolytic therapy. Catheter based embolectomy using Inari FlowTriever® was successfully performed in all the patients. As the data on this intervention is sparse, our case series highlights successful catheter based thrombo-embolectomies in high-risk individuals with right atrial clot in-transit with or without pulmonary embolism.
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Affiliation(s)
- Isha Verma
- Division of Cardiology, Morehouse School of Medicine, Atlanta, Georgia, USA.,Division of Cardiology, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Eric Y Chang
- Division of Cardiology, Morehouse School of Medicine, Atlanta, Georgia, USA.,Division of Cardiology, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Gautam Kumar
- Division of Cardiology, Atlanta Veterans Affairs Hospital, Decatur, Georgia, USA.,Division of Cardiology, Grady Memorial Hospital, Atlanta, Georgia, USA.,Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rajesh Sachdeva
- Division of Cardiology, Morehouse School of Medicine, Atlanta, Georgia, USA.,Division of Cardiology, Atlanta Veterans Affairs Hospital, Decatur, Georgia, USA.,Division of Cardiology, Grady Memorial Hospital, Atlanta, Georgia, USA
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40
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Suenaga H, Tsurukiri J, Kato T, Matsunaga K, Ogawa N, Oiwa A, Otake N, Numata J. Paradoxical Cerebral Embolization Caused by Thrombus-In-Transit via a Patent Foramen Ovale in a Patient with Symptomatic Pulmonary Embolism: A Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:805-810. [PMID: 37502001 PMCID: PMC10370931 DOI: 10.5797/jnet.cr.2021-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/15/2021] [Indexed: 07/29/2023]
Abstract
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.
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Affiliation(s)
- Hiroki Suenaga
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Junya Tsurukiri
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Takahisa Kato
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Kyosuke Matsunaga
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Naoko Ogawa
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Akito Oiwa
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Naruaki Otake
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Jushi Numata
- Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
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41
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Bayona Molano MDP, Salsamendi J, Mani N. Emergent mechanical thrombectomy for right atrial clot and massive pulmonary embolism using flowtriever. Clin Case Rep 2021; 9:1241-1246. [PMID: 33768819 PMCID: PMC7981718 DOI: 10.1002/ccr3.3739] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 11/27/2020] [Accepted: 12/12/2020] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Naganathan Mani
- Department of Interventional RadiologyMallinckrodt Institute of RadiologySt LouisMOUSA
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42
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Silaev AA, Epifanov SI, Shcherbatiuk KV, Kolomeĭchenko NA, Dvorianchikova VA, Avrusina EK. [Hybrid treatment of total thrombosis of the inferior vena cava]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:63-69. [PMID: 33332307 DOI: 10.33529/angio2020420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Described in the article is a clinical case report regarding successful surgical treatment of a female patient with total floating thrombosis of the inferior vena cava and thrombosis of the right atrium, complicated by pulmonary embolism. Our patient was a 42-year-old woman presenting with a clinical pattern of iliofemoral thrombosis. The examination revealed floating thrombosis of the inferior venal cava, right atrial thrombosis, and massive pulmonary embolism. Given the presence of absolute contraindications to systemic thrombolysis, it was decided to carry out surgical treatment by means of a hybrid-operation procedure. The woman underwent successful direct thrombectomy from the right-atrium cavity and branches of the pulmonary artery in conditions of artificial blood circulation, simultaneously accompanied by removing the floating thrombus from the inferior vena cava with the help of the 'Track' system, as well as by placement of a cava filter. Also presented herein is a review of the world experience gained in treating this pathology, followed by substantiation of using a hybrid approach for achieving an optimal clinical outcome.
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Affiliation(s)
- A A Silaev
- Clinical Hospital of the Presidential Administration of the Russian Federation, Moscow, Russia
| | - S Iu Epifanov
- Clinical Hospital of the Presidential Administration of the Russian Federation, Moscow, Russia
| | - K V Shcherbatiuk
- Clinical Hospital of the Presidential Administration of the Russian Federation, Moscow, Russia
| | - N A Kolomeĭchenko
- Clinical Hospital of the Presidential Administration of the Russian Federation, Moscow, Russia
| | - V A Dvorianchikova
- Clinical Hospital of the Presidential Administration of the Russian Federation, Moscow, Russia
| | - E K Avrusina
- Clinical Hospital of the Presidential Administration of the Russian Federation, Moscow, Russia
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43
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Belharty N, Azouzi RE, Chafai Y, Mouine N, Benyass A. Concomitant in situ and in transit right heart thrombi: a case report. Pan Afr Med J 2020; 37:355. [PMID: 33796169 PMCID: PMC7992397 DOI: 10.11604/pamj.2020.37.355.27416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 12/16/2020] [Indexed: 11/11/2022] Open
Abstract
Right heart thrombi can form in situ or lodge in the right cardiac chambers, originating from deep venous thrombosis. The latter carries a poor prognosis, taking into account the very high mortality rate. We herein report a case of an 83-year-old man who developed thrombus in the inferior vena cava that extended up to the right atrium, along with two distinct masses attached to the right ventricle wall.
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Affiliation(s)
- Najlaa Belharty
- Department of Cardiology, Mohamed V Military Hospital, Mohammed V University, Rabat, Morocco
| | - Rania El Azouzi
- Department of Cardiology, Mohamed V Military Hospital, Mohammed V University, Rabat, Morocco
| | - Yassmine Chafai
- Department of Cardiology, Mohamed V Military Hospital, Mohammed V University, Rabat, Morocco
| | - Najat Mouine
- Department of Cardiology, Mohamed V Military Hospital, Mohammed V University, Rabat, Morocco
| | - Aatif Benyass
- Department of Cardiology, Mohamed V Military Hospital, Mohammed V University, Rabat, Morocco
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44
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Khan HMW, Khan MR, Munir A, Moughrabieh A, Changezi HU. A Giant Right-Heart Thrombus-in-Transit in a Patient with COVID-19 Pneumonia. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e927380. [PMID: 33201863 PMCID: PMC7680708 DOI: 10.12659/ajcr.927380] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Patient: Male, 54-year-old Final Diagnosis: COVID-19 • right heart thrombus-in-transit Symptoms: Cough • dyspnea • fever • syncope Medication: — Clinical Procedure: — Specialty: Cardiology • Critical Care Medicine • Infectious Diseases
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Affiliation(s)
| | - Mahin Raqueeb Khan
- Department of Cardiovascular Disease, McLaren-Flint/Michigan State University, Flint, MI, USA
| | - Ahmad Munir
- Department of Cardiovascular Disease, McLaren-Flint/Michigan State University, Flint, MI, USA
| | - Anas Moughrabieh
- Department of Critical Care Medicine, McLaren-Flint/Michigan State University, Flint, MI, USA
| | - Hameem Unnabi Changezi
- Department of Cardiovascular Disease, McLaren-Flint/Michigan State University, Flint, MI, USA
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45
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Selwanos PPS, Ahmed AO, El Bakry KM, Elsharkawy AN, Mohamed OA, Hosny H, Samaan AAS. Management of a huge right atrial thrombus in a patient with multiple comorbidities. Egypt Heart J 2020; 72:79. [PMID: 33175249 PMCID: PMC7658281 DOI: 10.1186/s43044-020-00112-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 10/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Floating right heart thrombi (RHT) represent an underdiagnosed, potentially hazardous, and to some extent rare phenomenon in patients presenting with acute pulmonary embolism (APE). Emergent treatment is usually required for such a condition. CASE PRESENTATION A 19-year-old young lady presented with progressive shortness of breath, marked renal impairment, thrombocytopenia, and a highly oscillating huge right atrial mass. After she was admitted to the intensive care unit, she arrested in asystole and was resuscitated, and her electrocardiogram (ECG) showed evidence of acute anterior myocardial infarction. Urgent cardiac surgery to remove the right atrial mass was proposed by the heart team as the best option of management. Surgery was emergently performed with extra-corporeal membrane oxygenator (ECMO) as a support. Following surgery, mechanical support and vasopressors were successfully weaned and the patient achieved a good recovery. CONCLUSIONS A pulmonary embolism response team (PERT) approach should always be considered where a multidisciplinary team involving a cardiologist, radiologist, cardio-thoracic surgeon, radiologist, and intensivist shall determine the management strategy for a challenging presentation of a massive pulmonary embolism or floating right heart thrombi causing the hemodynamically unstable clinical condition.
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Affiliation(s)
- Peter Philip Shaker Selwanos
- Department of Cardiology, Aswan Heart Centre, Magdi Yacoub Foundation, 72 Kasr Elhagar street, Elsail Elegedeed, Aswan, PO 81511, Egypt.
| | - Ahmed Osman Ahmed
- Department of Cardiology, Aswan Heart Centre, Magdi Yacoub Foundation, 72 Kasr Elhagar street, Elsail Elegedeed, Aswan, PO 81511, Egypt.,Department of Cardiology, Cairo University Hospital, Cairo, Egypt
| | - Karim Mohamed El Bakry
- Department of Cardiology, Aswan Heart Centre, Magdi Yacoub Foundation, 72 Kasr Elhagar street, Elsail Elegedeed, Aswan, PO 81511, Egypt.,Department of Cardiology, Cairo University Hospital, Cairo, Egypt
| | - Ahmed Nazmy Elsharkawy
- Department of Intensive Therapy Unit, Postoperative Cardiac Surgery, Aswan Heart Centre, Magdi Yacoub Foundation, Aswan, Egypt
| | - Omar Alaaeldin Mohamed
- Department of Intensive Therapy Unit, Postoperative Cardiac Surgery, Aswan Heart Centre, Magdi Yacoub Foundation, Aswan, Egypt
| | - Hatem Hosny
- Department of Cardiac Surgery, Aswan Heart Centre, Magdi Yacoub Foundation, Aswan, Egypt
| | - Amir Anwar Shaker Samaan
- Department of Cardiology, Aswan Heart Centre, Magdi Yacoub Foundation, 72 Kasr Elhagar street, Elsail Elegedeed, Aswan, PO 81511, Egypt.,Department of Cardiology, Cairo University Hospital, Cairo, Egypt
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46
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Abstract
Thrombus in transit (TIT) remains an uncommon diagnosis. However, it is often found in patients diagnosed with acute pulmonary embolism (PE). While thrombolytics are mainly used in life-threatening presentations, their role in stable patients with a known history of intracranial hemorrhage (ICH) is unclear.
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47
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Trombo en tránsito. Arch Bronconeumol 2020; 56:537-539. [DOI: 10.1016/j.arbres.2020.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/22/2020] [Accepted: 04/13/2020] [Indexed: 11/20/2022]
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48
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Worm in My Heart. Ann Am Thorac Soc 2020; 16:760-764. [PMID: 31149859 DOI: 10.1513/annalsats.201810-723cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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49
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Kabrhel C, Rosovsky R, Garvey S. Special Considerations in Pulmonary Embolism: Clot-in-Transit and Incidental Pulmonary Embolism. Crit Care Clin 2020; 36:531-546. [PMID: 32473697 DOI: 10.1016/j.ccc.2020.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA.
| | - Rachel Rosovsky
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Shannon Garvey
- Boston University School of Medicine, 72 E Concord Street, Boston, MA 02118, USA
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50
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Tan CW, Balla S, Ghanta RK, Sharma AM, Chatterjee S. Contemporary Management of Acute Pulmonary Embolism. Semin Thorac Cardiovasc Surg 2020; 32:396-403. [PMID: 32353408 DOI: 10.1053/j.semtcvs.2020.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/13/2020] [Indexed: 11/11/2022]
Abstract
Multiple treatment options beyond anticoagulation exist for massive and submassive pulmonary embolism to reduce mortality. For some patients, systemic thrombolytics and catheter-directed thrombolysis are appropriate interventions. For others, surgical pulmonary embolectomy can be life-saving. Extracorporeal life support and right ventricular assist devices can provide hemodynamic support in challenging cases. We propose a management algorithm for the treatment of massive and submassive pulmonary embolism, in conjunction with a multidisciplinary pulmonary embolism response team, to guide clinicians in individualizing treatment for patients in a timely manner.
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Affiliation(s)
- Corinne W Tan
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sujana Balla
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Ravi K Ghanta
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Aditya M Sharma
- Department of Medicine, University of Virginia, Health Sciences Center, Charlottesville, Virginia
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas.
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