Pulmonary embolism during echocardiography: thrombus in transit/Ekokardiyografi yapilmakta olan hastada gelisen pulmoner emboli: gecis yapan thrombus.

An 85-year-old woman was admitted to our hospital's emergency ward with the signs of dyspnea, chest and right leg pain. On admission, she had a blood pressure of 110/80 mmHg and her heart rate was 100 beat/min. Physical examination revealed swelling and redness of the right leg which was tender. The electrocardiogram showed atrial fibrillation. Right leg ultrasonography revealed a deep venous thrombosis. Transthoracic echocardiography revealed a large thrombus floating in the right atrium, which eventually prolapsed into the right ventricle (Fig. 1-3, see corresponding video movie 1 at www.anakarder.com). The definite diagnosis of pulmonary embolism was concluded during echocardiography procedure, which demonstrated a large snake-like floating thrombus crossing tricuspid valve (Fig. 2, see corresponding video movie 2 at www.anakarder.com). The right ventricle was enlarged and severe tricuspid regurgitation was present. Her pulmonary artery pressure was 70 mmHg. She was stable after pulmonary embolism event without signs of clinical deterioration, shock or cyanosis. Heparin was started immediately (5000 IU bolus followed by an infusion of 1000 IU/h) and continued indefinitely during hospital stay. She was discharged with oral warfarin treatment and she is comfortable at present time.

[FIGURES 1-3 OMITTED]

Embolus in transit was first diagnosed by two-dimensional echocardiography in 1981 (1). Although transthoracic echocardiography can demonstrate the freely floating embolus inside the right heart chambers as in our case, conclusion of differential diagnosis from other sources of right heart masses should be made, especially if the thrombus is not mobile (2). Absence of a mobile mass on follow-up transthoracic echocardiography can also lead the diagnosis (3). Once the diagnosis of thrombus in transit was concluded emergent therapy can be life-saving, since it is an extreme therapeutic emergency and potentially lethal (4). Although the optimal management of right heart thromboemboli remains unclear since there are no prospective randomized trials comparing the treatment modalities; heparin should be administered to every patient. If pulmonary embolus is massive, thrombolytics are indicated (5). Surgical embolectomy should only be decided in cases of paradoxical emboli (6). Filter systems should also be considered since these patients carry a high risk of further embolic events. In cases of sub-massive emboli, routine thrombolytics administration may not be needed. Including our case, several cases of sub-massive pulmonary emboli due to thrombus in transit were reported in the literature, which were treated successfully with only heparin administration (7). Patients should receive subsequent oral anticoagulation which may be continued indefinitely if they carry high risk for recurrence.

References

(1.) Armstrong WF, Feigenbaum H, Dillon JC. Echocardiographic detection of right atrial thromboembolism. Chest 1985; 87: 801-6.

(2.) The European Cooperative Study on the clinical significance of right heart thrombi. European Working Group on Echocardiography. Eur Heart J. 1989; 10: 1046-59.

(3.) Eroglu S, Yildirir A, Simsek V, Muderrisoglu H. Right atrial mobile thrombus leading to pulmonary embolism. Anadolu Kardiyol Derg 2004; 4: 279-80.

(4.) Yazici M, Dinckal MH, Davutoglu V, Soydinc S, Akdemir I, Karaca M. Right atrial 'thrombus in transit' and atrial septal defect in a 70-year-old man: cardioembolic source of pulmonary and paradoxical cerebral embolization. Int J Cardiovasc Imaging 2004; 20: 213-5.

(5.) Cuccia C, Campana M, Franzoni P, Faggiano P, Volterrani M, Musmeci G, et al. Effectiveness of intravenous rTPA in the treatment of massive pulmonary embolism and right heart thromboembolism. Am Heart J 1993; 126: 468-72.

(6.) Chapoutot L, Metz D, Canivet E, Maillier B, Torossian F, Pommier JL, et al. Mobile thrombus of the right heart and pulmonary embolism: diagnostic and therapeutic problems. Apropos of 12 cases. Arch Mal Coeur Vaiss 1993; 86: 1039-45.

(7.) Delvigne M, Vermeersch P, Van den Heuvel P. Thrombus-in-transit causing paradoxical embolism in cerebral and coronary arterial circulation. Acta Cardiol 2004; 59: 669-72.

Hakan Ozhan, Ahmet Kaya, Mehmet Yazici, Sinan Albayrak, Enver Erbilen, Serkan Bulur

Department of Cardiology, Faculty of Medicine, Abant Izzet Baysal University, Duzce, Turkey Original Image Orijinal Goruntu

Address for Correspondence: Dr. Hakan Ozhan, Abant Izzet Baysal Universitesi Duzce Tip Fakultesi Kardiyoloji Klinigi, 81620 Konuralp Duzce, Turkey

Phone: [phone] Fax: [phone] E-mail: [e-mail]