|Year : 2015 | Volume
| Issue : 1 | Page : 21-23
Successful Treatment of Free-Floating Right Ventricular Thrombus with Acute Pulmonary Embolism
Sanjay Singhal1, Vivek Paliwal2, Srinivasa Alasinga Bhattachar3, Kamal Pathak4
1 Graded Specialist, Department of Medicine, 153-General Hospital, High Altitude Medical Research Centre, Leh, Jammu and Kashmir, India
2 Graded Specialist, Department of Radiodiagnosis, 153-General Hospital, High Altitude Medical Research Centre, Leh, Jammu and Kashmir, India
3 Senior Research Associate, Department of Radiodiagnosis, 153-General Hospital, High Altitude Medical Research Centre, Leh, Jammu and Kashmir, India
4 Consultant Radiologist, Department of Radiodiagnosis, 153-General Hospital, High Altitude Medical Research Centre, Leh, Jammu and Kashmir, India
|Date of Web Publication||14-Mar-2015|
153-General Hospital, Leh, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Acute pulmonary embolism with floating right intra-ventricular thrombus is a rare phenomena associated with poor prognosis. Here, we are presenting a case of 35-year-young male with no co-morbid illness diagnosed to have right ventricular thrombus with bilateral pulmonary embolism, which was managed successfully with thrombolytic therapy.
Keywords: Intra-ventricular thrombus, pulmonary embolism, thrombolysis
|How to cite this article:|
Singhal S, Paliwal V, Bhattachar SA, Pathak K. Successful Treatment of Free-Floating Right Ventricular Thrombus with Acute Pulmonary Embolism. Heart India 2015;3:21-3
|How to cite this URL:|
Singhal S, Paliwal V, Bhattachar SA, Pathak K. Successful Treatment of Free-Floating Right Ventricular Thrombus with Acute Pulmonary Embolism. Heart India [serial online] 2015 [cited 2019 Dec 10];3:21-3. Available from: http://www.heartindia.net/text.asp?2015/3/1/21/153282
| Introduction|| |
Right Ventricular thrombus presenting with acute pulmonary embolism is a rare phenomena associated with poor prognosis. Here we are presenting one such case who was managed successfully with thrmbolytic therapy.
| Case report|| |
A 35-year-old young soldier with no co-morbid illness was air-evacuated from 18,400 feet to our hospital (located at 11,500 feet) with a history of right upper abdominal pain. He had a tachycardia of 112/min, respiratory rate of 35/min, blood pressure of 110/70 mm Hg and oxygen saturation of 88% on room air. Hematological and biochemical parameters were normal. Ultrasound of the abdomen was otherwise normal except mild ascites. 12-lead electrocardiogram revealed tachycardia with T-wave inversion in lead V1-V4. Chest radiograph revealed a significant cardiomegaly. Bedside trans-thoracic echocardiography showed a moderately dilated right ventricle with impaired right ventricular systolic function containing a large free echogenic mass consistent with a thrombus with normal pulmonary artery pressure [Figure 1]. Urgent computed tomography pulmonary angiography revealed massive bilateral pulmonary embolism [Figure 2] and [Figure 3]. Patient was started on oxygen inhalation, low-molecular-weight heparin and oral anticoagulation.
On next day, patient developed hypotension (blood pressure of 80 mm Hg systolic). Immediately, he was given intravenous tissue plasminogen activator. Postthrombolytic therapy, his blood pressure improved and oxygen requirement also decreased. Repeat trans-thoracic echocardiography performed after 12 h showed no evidence of the right ventricular thrombus [Figure 4]. Subsequently, he was maintained on intravenous heparin and switched over to long-term oral anticoagulation. Follow-up trans-thoracic echocardiography showed improved right ventricular function. Patient was transferred to a tertiary center at near sea-level and was followed-up for 2 months. Subsequent recovery was uneventful, and the patient was discharged on anticoagulation after 2 months.
|Figure 2: Computed tomography angiography showing bilateral pulmonary embolism|
Click here to view
|Figure 3: Computed tomography angiography showing bilateral pulmonary embolism|
Click here to view
|Figure 4: Echocardiography showing resolution of intracavitary thrombus after thrombolysis|
Click here to view
| Discussion|| |
In high altitude scenario, a rare case of biventricular thrombus has been reported to be associated with protein S deficiency.  Right heart thrombus when present with pulmonary thromboembolism is associated with greater mortality. In a study where 2454 cases of pulmonary embolism were studied and 1113 cases were described, 42 cases of right heart thrombus had twice the mortality rate at 14 days and 3 months of 21% and 29% respectively compared to mortality rate of 11% and 16% respectively in cases of pulmonary embolism.  The findings of hemodynamic compromise like in our case such as hypotension (systolic blood pressure [SBP] <90 mm Hg) in cases of right heart thrombus were observed in 14% of cases compared to 4% of cases of pulmonary embolism without right heart thrombus. 
The mortality in the cases of right heart thrombus treated with heparin alone, thrombolysis and surgical embolectomy was 23.5%, 20.8% and 25% respectively.  In another retrospective study, which analyzed 177 cases of right heart embolism, mortality rate in cases with no therapy, anticoagulation therapy, surgical embolectomy and thrombolysis was 100%, 28.6%, 23.8% and 11.3% respectively.  Further analysis revealed association of improved survival rate associated with thrombolysis therapy compared to other treatment options.  The difference in the treatment-associated mortality in cases of right heart thrombus is attributed to subject selection, presence of co-morbidities determining treatment selection and varying number of cases treated in the three treatment option groups.
The most common complication associated with thrombolysis was bleeding that occurred in 21.9% of the cases compared to a rate of 7.9% in cases treated with heparin alone.  A review of described recent studies showing occurrence of bleeding between 20% and 25% of treated cases and 5-10% major bleeding.  The commonest site for a major bleed was intracranial with a mortality of 50%. 
Acute pulmonary embolism with floating right intra-ventricular thrombus is a rare phenomena associated with poor prognosis. , American college of chest physicians  suggest that the thrombolytic therapy should be administered in the patient with acute pulmonary embolism associated with hypotension (SBP <90 mm Hg) (as in our case). This case illustrates uncommon clinical presentation of uncommon right ventricular thrombus with bilateral pulmonary embolism and underlies the importance of serial echocardiography as a key examination in patients with a suspected embolism.
| References|| |
Malani S, Chadha D, Banerji A. Biventricular thrombosis in a structurally normal heart at high altitude. BMJ Case Rep 2014; 2014.
Torbicki A, Galie N, Covezzoli A, Rosi E, De Rosa M, Goldhaber SZ; ICOPER Study Group. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol 2003;41:2245-51.
Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest 2002;121:806-14.
Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser K, Rauber K, et al.
Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with major pulmonary embolism: Results of a multicenter registry. Circulation 1997;96:882-8.
Almoosa K. Is thrombolytic therapy effective for pulmonary embolism? Am Fam Physician 2002;65:1097-102.
The European Cooperative Study on the clinical significance of right heart thrombi. European Working Group on Echocardiography. Eur Heart J 1989;10:1046-59.
Chartier L, Béra J, Delomez M, Asseman P, Beregi JP, Bauchart JJ, et al.
Free-floating thrombi in the right heart: Diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation 1999;99:2779-83.
Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuünemann HJ, American College of Chest Physicians Antithrombotic Therapy and Prevention of Thrombosis Panel. Executive summary: Antithrombotic therapy and prevention of thrombosis, 9 th
ed: American college of chest physicians evidence-based clinical practice guidelines. Chest 2012;141:7S-47
[Figure 1], [Figure 2], [Figure 3], [Figure 4]