Cardiogenic shock due to huge right atrial thrombus

Treatment of right heart thromboemboli

BACKGROUND

The presence of right heart thromboemboli complicating pulmonary thromboemboli carries with it an increased mortality rate compared to pulmonary thromboemboli alone, but little is known about the optimal management of this difficult clinical situation. This fact is highlighted in the case study of a patient with a 19-cm right atrial thrombus complicating bilateral pulmonary thromboemboli.

STUDY OBJECTIVES

We sought to determine the effects of anticoagulation therapy, thrombolysis, and surgical embolectomy on mortality rate in patients with right heart thromboemboli.

DESIGN

Retrospective analysis of all reported cases in the English language literature (1966 to 2000) of right heart thromboembolism in which age, sex, therapy, and outcome were reported.

MEASUREMENTS AND RESULTS

We analyzed 177 cases of right heart thromboembolism. Pulmonary thromboembolism was present in 98% of the cases. The patients were evenly divided by gender with an average age of 59.8 years (SD, 16.6 years) years. Dyspnea (54.2%), chest pain (22.6%), and syncope (17.5%) were the most common presenting symptoms. The treatments administered were none (9%), anticoagulation therapy (35.0%), surgical procedure (35.6%), or thrombolytic therapy (19.8%). The overall mortality rate was 27.1%. The mortality rate associated with no therapy, anticoagulation therapy, surgical embolectomy, and thrombolysis was 100.0%, 28.6%, 23.8%, and 11.3%, respectively. Using multivariate modeling with survival as the primary outcome, age and gender were not associated with mortality rate, but thrombolytic therapy was associated with an improved survival rate (p < 0.05) when compared either to anticoagulation therapy or surgery.

CONCLUSION

The presence of right heart thromboemboli may have diagnostic and therapeutic implications in pulmonary thromboembolism patients. A well-designed prospective, randomized trial is needed to determine the optimal treatment of right heart thromboemboli.

Acute pulmonary thromboembolism with a floating right-heart thrombus. 4 surgical cases

OBJECTIVE

We determined the efficacy of surgery for acute pulmonary thromboembolism with a floating right-heart thrombus.

METHODS AND RESULTS

Thrombi were diagnosed by transthoracic echocardiography and electron beam computed tomography in 4 patients with acute pulmonary thromboembolism with a floating right-heart thrombus, and thromboembolectomy was done in all patients. Surgical procedure included intermittent deep hypothermic circulatory arrest. One patient died of endobronchial hemorrhage and 3 survived.

CONCLUSION

Because acute pulmonary thromboembolism with a right-heart thrombus is life-threatening, immediate thromboembolectomy is required to decrease mortality.

Large right atrial thrombus with pulmonary embolism

We present the cases of two patients, aged 67 and 77 years, who were admitted for the evaluation of rapidly progressive dyspnea and syncope, respectively. Both patients developed large right atrial thrombi with pulmonary embolism. The first patient received recombinant tissue plasminogen activator and survived with an uneventful result, whereas the second patient received operative thrombectomy followed by intravenous heparin and died 15 days later of pulmonary infarction with pulseless electrical activity. Data from these limited experiences suggest that thrombolytic therapy might be considered in patients with right heart thrombi with pulmonary embolism.