Free-Floating Right Heart Thrombus with Acute Massive Pulmonary Embolism: A Case Report and Review of the Literature

Free-floating right heart thrombus (RHT) is an extreme medical emergency in the context of acute massive pulmonary embolism (PE). Despite the advances in early diagnosis, the management is still very debatable due to lack of consensus. We reported the case of a 66-year-old male, with a history of moderate renal dysfunction and dilated cardiomyopathy, who presented to the emergency department for acute dyspnea. His angiographic magnetic resonance imaging revealed bilateral extensive PE. Transthoracic echocardiography showed RHT with moderate right ventricular dysfunction and pulmonary hypertension. Venous Doppler of the lower extremities noted the presence of a floating clot in the right common femoral vein. The patient was managed successfully by thrombolytic therapy with tenecteplase. To the best of our knowledge, this is the first case report of RHT and PE from Lebanon. Published cases from Middle Eastern countries are scarse.

Right Heart Thrombus in an Adult COVID-19 Patient: A Case Report

INTRODUCTION

Right heart thrombus (RiHTh) can be considered a rare and severe condition associated with thromboembolic phenomena. A case is described of a COVID-19 patient presenting with an isolated thrombus in the right ventricle.

CASE PRESENTATION

An 80-years-old Caucasian male was admitted in an intensive care unit (ICU) for COVID-19 related acute respiratory distress syndrome. The patient showed signs of hemodynamic instability, elevated cardiac troponin I and altered coagulation. On further assessment, a thrombotic mass near the apex of the right ventricle was detected. Moreover, the apex and the anteroseptal wall of the right ventricle appeared akinetic. Following the administration of a therapeutic dose of unfractionated heparin over a forty-eight hour period, re-evaluation of the right chambers showed that the thrombotic mass had resolved entirely.

CONCLUSION

COVID-19 patients could constitute a population at risk of RiHTh. Routine use of echocardiography and a multidisciplinary approach can improve the management of this condition.

Successful thrombolysis using recombinant tissue plasminogen activator in cases of severe pulmonary embolism with mobile thrombi in the right atrium

Hereby, we report two cases of acute pulmonary embolism with concomitant right-sided thrombus, which were successfully treated using recombinant tissue plasminogen activator (rtPA). These patients had life-threatening acute right ventricular failure, which dramatically improved within hours following thrombolysis. These cases emphasize the clinical utility of rtPA for the treatment of life-threatening pulmonary embolism.

Emergent mechanical thrombectomy for right atrial clot and massive pulmonary embolism using flowtriever

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.

Acute pulmonary embolism with coexisting right heart thrombi in transit-surgical treatment of 20 consecutive patients

OBJECTIVES

The presence of right heart thrombi in transit in the setting of acute pulmonary embolism is associated with high mortality. The optimal management in such cases is inconclusive. We present the results of surgical treatment of 20 consecutive patients diagnosed with high or intermediate-high risk pulmonary embolism with coexisting right heart thrombi in transit.

METHODS

A retrospective analysis was performed of all consecutive patients undergoing surgical treatment in the Medicover Hospital between 2013 and 2021 for acute pulmonary embolism with coexisting thrombi in-transit in right heart cavities. The diagnosis was based on echocardiography, computed tomography pulmonary angiography, and laboratory tests. Eligibility criteria for surgical treatment were acute pulmonary embolism with right heart thrombi in transit, right ventricular overload on imaging studies, and significantly elevated levels of cardiac troponin and NTproBNP. All patients were operated on with extracorporeal circulation using deep hypothermia and total circulatory arrest. The primary end-point was hospital all-cause mortality; secondary end-points were perioperative complications and long-term mortality.

RESULTS

The analysis included 20 patients. There was no in-hospital death. Nearly one-third of patients required temporal hemofiltration for postoperative renal failure, but this did not involve the need for dialysis at discharge. No neurological complications occurred in any patient. The mean follow-up was 46 months (range 13-98). There was one death in the long-term follow-up, not related to pulmonary embolism.

CONCLUSIONS

Surgical treatment of patients with acute pulmonary embolism and coexisting right heart thrombi in transit can provide favourable results.

Right Heart Clot-in-Transit: Endovascular Therapies

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.

Successful treatment of right heart thrombus and high-risk pulmonary embolism with acoustic pulse thrombolysis using EKOS endovascular system

Currently, the only widely accepted indication for interventional treatment in cases of pulmonary embolism is hemodynamic instability or cardiogenic shock. However, the presence of a right-heart thrombus along with a pulmonary embolism is a poor prognostic indicator, and catheter directed thrombolysis with use of thrombolytic agents should also be considered in this circumstance. Optimal management of right heart thrombus and high-risk pulmonary embolism is still uncertain. Herein, we present the case of an 81-year-old woman who presented at our hospital after progressive dyspnea and a syncopal event. The transthoracic echocardiography showed massive bilateral pulmonary, right ventricular and mobile atrial thrombus and also right-sided enlargement. The patient was successfully treated with acoustic pulse thrombolysis using the EKOS EkoSonic system and echocardiography revealed complete resolution of her right-heart thrombus and her high-risk pulmonary embolism 2 days later.

Right heart thrombus-in-transit in a patient with Evans syndrome: A case report

INTRODUCTION

Right heart free-floating thrombus in the absence of structural heart disease or atrial fibrillation is rare. When it travels to the heart into the lung, called thrombus-in-transit, may cause cardiopulmonary collapse and sudden death. The clinical presentation varies from mild respiratory symptoms to sudden death; however, there are few clinical case reports of giant, free-floating thrombus in the right heart in an asymptomatic patient, and the optimal management options have not been established.

PATIENT CONCERNS

A 36-year-old Asian woman presented to the emergency department with complaints of worsening swelling of the left lower extremity over 12 hours.

DIAGNOSIS

Left leg deep vein thrombosis accompanied by an asymptomatic giant right atrial thrombus and pulmonary embolism with a rare autoimmune disease of Evans syndrome.

INTERVENTIONS

Emergent surgical thrombectomy under cardiopulmonary bypass for right atrial thrombus.

OUTCOMES

The postoperative course was uneventful, and she was discharged on the eighth postoperative day with normal heart function and mild tricuspid regurgitation.

CONCLUSION

An additional diagnostic workup in cases of deep vein thrombosis is necessary for the rapid diagnosis of right heart thrombus and pulmonary embolism without delay. This case report illustrates that early recognition of venous thromboembolism and emergent thrombectomy of right heart thrombus-in-transit is crucial to prevent mortality.

Massive obliterative right heart thrombus presenting with near-syncope

Intracardiac thrombi are commonly encountered as a complication of a recent myocardial infarction, heart failure, atrial fibrillation, or intracardiac devices. The prevalence of atrial thrombi in the absence of these risk factors is not well-described, but seems to be low. We present a case of a 51-year-old man with a massive mobile thrombus in the right heart extending through the tricuspid valve, diagnosed on echocardiography after presenting with a presyncopal episode.

What echocardiographic findings differentiate acute pulmonary embolism and chronic pulmonary hypertension?

BACKGROUND

Pulmonary embolism (PE) and pulmonary hypertension (PH) are potentially fatal disease states. Early diagnosis and goal-directed management improve outcomes and survival. Both conditions share several echocardiographic findings of right ventricular dysfunction. This can inadvertently lead to incorrect diagnosis, inappropriate and potentially harmful management, and delay in time-sensitive therapies. Fortunately, bedside echocardiography imparts a few critical distinctions.

OBJECTIVE

This narrative review describes eight physiologically interdependent echocardiographic parameters that help distinguish acute PE and chronic PH. The manuscript details each finding along with associated pathophysiology and summarization of the literature evaluating diagnostic utility. This guide then provides pearls and pitfalls with high-quality media for the bedside evaluation.

DISCUSSION

The echocardiographic parameters suggesting acute or chronic right ventricular dysfunction (best used in combination) are: 1. Right heart thrombus (acute PE) 2. Right ventricular free wall thickness (acute ≤ 5 mm, chronic > 5 mm) 3. Tricuspid regurgitation pressure gradient (acute ≤ 46 mmHg, chronic > 46 mmHg, corresponding to tricuspid regurgitation maximal velocity ≤ 3.4 m/sec and > 3.4 m/sec, respectively) 4. Pulmonary artery acceleration time (acute ≤ 60-80 msec, chronic < 105 msec) 5. 60/60 sign (acute) 6. Pulmonary artery early-systolic notching (proximally-located, higher-risk PE) 7. McConnell's sign (acute) 8. Right atrial enlargement (equal to left atrial size suggests acute, greater than left atrial size suggests chronic).

CONCLUSIONS

Emergency physicians must appreciate the echocardiographic findings and associated pathophysiology that help distinguish acute and chronic right ventricular dysfunction. In the proper clinical context, these findings can point towards PE or PH, thereby leading to earlier goal-directed management.

Management of Pulmonary Embolism With Thrombus in Transit: A Case Series and an Updated Clinical Insight Review

Clot-in-transit (CIT) refers to a thrombus temporarily lodged in the right heart chambers, representing a critical and rare complication of venous thromboembolism, particularly in patients with acute pulmonary embolism (PE). This condition poses a significant risk of morbidity and mortality. This report provides a comprehensive overview of CIT in the context of PE, focusing on its definition, etiopathogenesis, risk classification, clinical manifestations, imaging findings, and treatment options. A retrospective review of CIT cases in PE patients at our institution was conducted, complemented by a detailed literature review. Data were analyzed to highlight the clinical findings, imaging results, and diverse treatment strategies employed. Five cases of CIT associated with PE are presented, illustrating varied risk factors, clinical presentations, and imaging findings. Treatment modalities included anticoagulation, thrombolysis, and surgical thrombectomy. Each case underscores the diagnostic challenges and management complexities inherent to CIT. CIT is a life-threatening complication of pulmonary thromboembolism. Early identification and individualized treatment are essential for improving outcomes. This case series provides valuable insights into CIT management and emphasizes the importance of multidisciplinary approaches for optimal patient care.

Outcomes with treatment interventions for clot-in-transit in patients with pulmonary embolism: a meta-analysis

OBJECTIVES

Clot-in-transit (CIT) in patients with pulmonary embolism (PE) has been associated with a high mortality rate and poor prognosis. The aim of this study was to evaluate the pooled efficacy of each of the 4 interventions (anticoagulation [AC] alone, systemic thrombolytic [ST] therapy, surgical thrombectomy, and catheter-based thrombectomy [CBT]) using mortality as the primary outcome.

METHODS

A time limited search until March 28, 2024 was conducted using PubMed (National Institutes of Health) and EMBASE (Elsevier) databases.

RESULTS

Thirteen studies (6 retrospective, 4 non-randomized prospective, and 3 pooled studies of case-reports) were included in the calculation of weighted proportion of mortality, including a total of 492 patients with CIT and PE with a mean age of 60.6 years; 50.1% were males. ST was the most frequently used treatment intervention (38.2%), followed by surgical thrombectomy (33.8%), AC alone (22.6%), and CBT (5.9%). The unweighted mortality was highest with AC alone 32.4% (36/111), followed by surgical thrombectomy 23.2% (38/164), CBT 20.7% (6/29), and ST 13.8% (26/188). The weighted mortality for AC alone was 35% (95% CI, 21% to 49%; 12 studies), surgical thrombectomy was 31% (95% CI, 16% to 47%; 12 studies), CBT was 20% (95% CI, 6% to 34%; 3 studies), and ST was 12% (95% CI, 5% to 19%; 12 studies).

CONCLUSIONS

In this meta-analysis of patients with CIT and PE, the highest mortality was observed with AC alone, followed by surgical thrombectomy, CBT, and ST therapy. However, there remains a need for randomized clinical trial data to determine the best treatment.

Clinical characteristics and treatment of patients with central pulmonary embolism and right heart thrombus

INTRODUCTION

Right heart thrombus (RHT), also known as clot in transit, is an uncommon finding in pulmonary embolism (PE) that is associated with increased inpatient mortality. To date, there is no consensus on the management of RHT. Therefore, we aim to describe the clinical features, treatments, and outcomes of patients with simultaneous RHT and PE.

METHODS

This is a retrospective, cross-sectional, and single-center study of hospitalized patients with central PE who had RHT visualized on transthoracic echocardiography (TTE) from January 2012 to May 2022. We use descriptive statistics to describe their clinical features, treatments, and outcomes, including mechanical ventilation, major bleeding, inpatient mortality, length of hospital stay, and recurrent PE on follow-up.

RESULTS

Of 433 patients with central PE who underwent TTE, nine patients (2%) had RHT. The median age was 63 years (range 29-87), most were African American (6/9), and females (5/9). All patients had evidence of RV dysfunction and received therapeutic anticoagulation. Eight patients received RHT-directed interventions, including systemic thrombolysis (2/9), catheter-directed suction embolectomy (4/9), and surgical embolectomy (2/9). Regarding outcomes, 4/9 patients were hemodynamically unstable, 8/9 were hypoxemic, and 2/9 were mechanically ventilated. The median length of hospital stay was six days (range 1-16). One patient died during hospital admission, and two patients had recurrent PE.

CONCLUSION

We described the different therapeutic approaches and outcomes of patients with RHT treated in our institution. Our study adds valuable information to the literature, as there is no consensus on the treatment of RHT.

HIGHLIGHTS

Right heart thrombus (RHT) was a rare finding in central pulmonary embolism. Most patients with RHT had evidence of RV dysfunction and pulmonary hypertension. Most patients received RHT-directed therapies in addition to therapeutic anticoagulation.

Right heart thrombus causing syncope in an elderly patient

Pulmonary embolism and thromboembolic disease carry a high mortality if not recognised and managed appropriately. Herein we illustrate the case of a dehydrated elderly female patient with recurrent syncope who proved to have high risk pulmonary embolism and a free floating right heart thrombus. The echocardiographic findings of right heart thrombus and possible thrombi 'in transit' within a low flow inferior vena cava, guided a life-saving treatment in this frail elderly patient.

A case report of a spherical mass in the right atrium: myxoma or thrombus?

Background

Intracardiac masses encompass a spectrum of pathologies, including tumors, thrombi, and other proliferative lesions, with left atrial involvement being more common than right atrial involvement. In particular, spherical thrombi in the right atrium are exceedingly rare. Diagnostic evaluation relies on modalities such as transesophageal echocardiography (TEE), cardiac magnetic resonance imaging (CMR), and multidetector computed tomography (MDCT). TEE provides detailed information regarding the mass's location, number, size, and mobility, while CMR and MDCT offer insights into tissue characterization. In this report, we describe a case in which both TEE and CMR misdiagnosed a spherical thrombus as a myxoma. By analyzing the features of TEE and CMR, we summarize the reasons for this misdiagnosis, aiming to serve as a cautionary reminder for clinicians.

Case summary

We report a case of a 59-year-old male, whose past medical history was notable only for a childhood lower extremity trauma (details unknown and not requiring hospitalization or treatment) and no history of diabetes, hypertension, prolonged immobilization, or familial diseases. A spherical mass was incidentally detected in the right atrium during a routine examination. Initial transesophageal echocardiography (TEE), including three-dimensional imaging, revealed a hyperechoic mass with a distinct stalk attached to the interatrial septum near the inferior vena cava, findings that were initially interpreted as consistent with a myxoma. However, subsequent surgical resection and histopathological analysis demonstrated fibrous tissue proliferation and collagenization, confirming the lesion as a thrombus. The unique spherical configuration and its location underscore the potential for misdiagnosis when relying solely on conventional imaging modalities.

Conclusion

Right atrial thrombi are rare findings observed on echocardiography. This case illustrates an incidental spherical thrombus located near the inferior vena cava entrance at the top of the right atrium. The echocardiographic features of this thrombus can resemble those of a myxoma, necessitating careful differentiation through additional examinations. In this case, the misdiagnosis on TEE was attributed to the mass displaying slightly increased echogenicity, a narrow attachment to the right atrium near the inferior vena cava, and a degree of mobility. Typically, thrombi appear hypoechoic; however, the slightly elevated echogenicity observed here may be due to the chronicity of thrombus formation, which could also account for the narrow attachment. According to the PLACE-T scoring system, the following points were assigned:P (Patient history): 0 points.L (Lobulation): Lobulated contour, 0 points.Attachment site width: Narrow stalk (base diameter/maximal diameter <0.3), +2 points.Clinical context: No relevant medical history, 0 points.Echogenicity pattern: Heterogeneous echogenicity, +1 point.T (Tissue characterization): No specific features, 0 points.With a total score of 3 points, the probability of a thrombus is high (sensitivity 92% and specificity 85% for scores ≤3). When TEE is not feasible or yields uncertain findings, other non-invasive imaging modalities such as multi-slice spiral CT (MDCT) or cardiac magnetic resonance imaging (CMR) may be considered. Although these techniques are predominantly used for left atrial assessment-MDCT, for instance, can successfully identify left atrial thrombus with a negative predictive value of 100% and a positive predictive value ranging from 41% to 92%-the accuracy of differentiating right atrial masses remains uncertain. Therefore, in similar cases, it is imperative to integrate the patient's clinical history, multiple auxiliary examination results, and the PLACE-T score rather than relying solely on the features observed on TEE.

Pulmonary embolism in transit

A 65-year-old woman with recently diagnosed ovarian cancer presented with near syncope, tachypnea, and hypoxia. Transthoracic echocardiography revealed a dilated and hypokinetic right ventricle and a large, mobile mass in the right atrium prolapsing across the tricuspid valve. She was diagnosed with pulmonary embolism in transit and emergent embolectomy was recommended.

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

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

Right heart thrombus in acute pulmonary embolism: A single center experience in China

Right heart thrombus (RHT) is a rare but life-threatening condition in acute pulmonary embolism (APE) without clear management guidelines. This study aimed to address the clinical characteristics and outcomes of RHT-APE in Chinese patients. In this study, 17 RHT-APE and 329 non-RHT-APE patients, who were diagnosed between September 2015 and August 2019, were retrospectively recruited with the median follow-up was 360 days. The overall prevalence of RHT was 4.91% in APE. Its prevalence increased along the increase of APE risk stratifications. Comparisons showed that with higher proportion of male gender and younger age, RHT-APE patients also had worse hemodynamic instability and heart function, and higher risk stratification levels than non-RHT-APE patients. After adjusting by age and gender, multivariate logistic regression analysis found high/intermediate-high risk stratification, decreased right ventricular (RV) motion, NT-proBNP >600 pg/mL, and RV dysfunction were risk factors for RHT. Kaplan-Meier analysis showed non-RHT had better prognosis than RHT patients (30-day survival: log-rank: p < 0.001; 90-day survival: log-rank: p = 0.002). The multivariate logistic regression analysis showed RHT was an independent risk factor for 30-day mortality in APE. The subgroup analysis showed RHT would result in worse outcomes in patients who already had higher APE early mortality risk. RHT would increase the risk of 30- and 90-day mortality in APE. More attention should be paid to young male APE patients with decreased RV motion, NT-proBNP >600 pg/mL, RV dysfunction, or high level of risk stratification, to exclude the coexistence of RHT.

Mobile right heart thrombus with pulmonary embolism in a patient with polycythemia rubra vera and splanchnic vein thrombosis

Splanchnic vein thrombosis in patients with polycythemia rubra vera is well-known. Development of mobile right heart thrombus in these patients has not been reported previously. We describe a young patient with Polycythemia rubra vera and splanchnic vein thrombosis with ischemic bowel who underwent small bowel resection. He developed a large mobile right atrial thrombus and bilateral pulmonary embolism. He also had upper gastrointestinal bleed. His management was complicated and challenging due to multiple risk factors and co-morbid conditions. Thrombolysis was contraindicated and he refused surgical intervention. He was treated with anticoagulation with complete resolution of right atrial thrombus.