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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 1  |  Issue : 1  |  Page : 24-26

Morphology of right heart thrombi in pulmonary embolism: A case series and analysis


Institute of Cardiology, Madras Medical College and RGGGH, Chennai, Tamil Nadu, India

Date of Web Publication7-Apr-2017

Correspondence Address:
Nisamudeen Kajamohideen
Institute of Cardiology, Madras Medical College and RGGGH, Chennai - 600 003, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.JIAE_20_17

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  Abstract 

Introduction: The occurrence of right heart thrombus (RiHT) in pulmonary embolism (PE) carries poor prognosis. Type A Thrombi are serpiginous, highly mobile with high mortality. Type B Thrombi are less mobile and have better prognosis. Type C is intermediate in all characteristics. Methods: This is an observational study done in patients presenting with RiHT with PE to the emergency unit of our institute from March to August 2016. A total of seven patient's clinical and electrocardiographic data were collected with a history of deep vein thrombosis or hypercoagulability. Results: This case series of seven patients with right heart thrombi in pulmonary embolism showed a predominance of male patients, with right ventricle dysfunction and pulmonary hypertension in all cases. Conclusion: Early fibrinolysis in type A thrombus had a favourable outcome. Mortality was 29% in our series.

Keywords: Echocardiography, outcomes, right heart thrombi, treatment, thrombi types


How to cite this article:
Kajamohideen N, Swaminathan N, Palanisamy G, Gnanavelu G, Sangareddi V. Morphology of right heart thrombi in pulmonary embolism: A case series and analysis. J Indian Acad Echocardiogr Cardiovasc Imaging 2017;1:24-6

How to cite this URL:
Kajamohideen N, Swaminathan N, Palanisamy G, Gnanavelu G, Sangareddi V. Morphology of right heart thrombi in pulmonary embolism: A case series and analysis. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2017 [cited 2017 Oct 22];1:24-6. Available from: http://www.jiaecho.org/text.asp?2017/1/1/24/204065


  Introduction Top


Right heart thrombus is associated with a variety of aetiologies causes. The occurrence of a right heart thrombus RiHT in pulmonary embolism (PE) carries a poor prognosis.

Aim

This study aims to study the correlation of morphological types of right heart thrombi (RiHT) found in acute PE with clinical presentation of the patients, need for thrombolytic therapy, and outcome after acute treatment.

Background

RiHT in PE is found in 4–18% of the cases aetiologies. RiHT represents a spectrum of disease with deep venous thrombosis (DVT) at one end, RiHT in middle, and PE at the other end. Type A Thrombi are serpiginous, highly mobile with high incidence of deep vein thrombosis, less incidence of intracardiac abnormalities and requiring emergency treatment. Mortality in Type A RiHT cases ranges from 28% to 44%. Type B thrombus is less mobile, pedunculated, broadbased with an underlying intracardiac abnormality, less incidence of DVT, more chances of embolization and have better prognosis. Type C RiHT has all features intermediate between Type A and B. The treatment options include anticoagulants, fibrinolysis, and surgery (pulmonary embolectomy).[1]


  Materials and Methods Top


This is an observational study done in patients presenting with RiHT with PE to the emergency unit of our institute from March to August 2016. A total of seven patient's clinical and electrocardiographic data were collected with a history of deep vein thrombosis or hypercoagulability. A detailed echocardiography was done on admission and daily in the 1st week and at 2nd week including various parameters such as size, Types (A, B, or C) based on Kronig 1989[2] classification and location of RiHT, LV function by Teicholz aetiologies method, right atrium and right ventricular (RV) dimensions, RV function by tricuspid annular plane systolic excursion (TAPSE), sizes of main pulmonary artery (MPA), right pulmonary artery (RPA), and left pulmonary artery (LPA), pulmonary acceleration time and presence of pericardial effusion.[3],[4],[5] TAPSE of 16 mm and below was considered as RV systolic dysfunction.[6],[7],[8] Tissue Doppler study of RV was done to assess RV diastolic dysfunction. The total duration of breathlessness, severe breathlessness duration, type of acute PE as massive, submassive, and nonmassive (according to Jaff et al.),[9] risk scores using simplified pulmonary embolism severity index (sPESI) were recorded. Doppler study for DVT of lower limbs and computed tomography pulmonary angiography (CTPA) were done in all cases, except one case who succumbed to death in the initial few hours during the thrombolysis. Patients with massive PE were treated with thrombolysis using 2.5 lakh units of Streptokinase over 1 h and 1 lakh units/h for 48 h, followed by heparin infusion and oral Vitamin K antagonists. Patients with submassive PE were treated with heparin infusion and oral Vitamin K antagonists. Outcomes were recorded as death, repeated hospitalization for worsening symptoms or symptomatically better on follow-up.


  Results Top


Among seven cases, the majority were males (6). Mean age at presentation was 31 years; maximum age was 46 years, and minimum 23 years. Mean total duration of breathlessness was 2.8 months (84 days) and severe breathlessness for 11 days. Thrombophilia was seen in one case. The mean MPA diameter was 29 mm (26–34); RPA was 15 mm (13–17); LPA 14.5 mm (14–15). Almost all patients (6) had RV systolic dysfunction, and TAPSE mean of 12.5 mm (10–14).

The majority was submassive (4/7) and others were massive (3 cases) [Figure 1], [Figure 2], [Figure 3]. Types A, B, and C of RiHT were found in 4, 2, and 1 cases, respectively. All the three massive PE cases were lysed with Streptokinase, 2 died (case 2 and case 7) and one improved (case no 5) and better at follow-up. Four patients had low-risk sPESI score (score 1), and three patients had a high risk (>1). Out of the three patients with high-risk sPESI score, 2 cases died and one survived after thrombolytic therapy by the early administration of Streptokinase (1 h).
Figure 1: Case 2: Type C - clot

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Figure 2: Case 4 - Type B - calcified

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Figure 3: Case 5 - Type A - right atrium-patent foramen ovale-left atrium

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There was evidence of pulmonary hypertension in all the cases with tricuspid regurgitation PG of 58 mmHg, reduced pulmonary acceleration time of 60–90 ms (average of 71 ms). Pericardial effusion was seen in two cases (cases 2 and 4). In case 2, CTPA showed saddle embolus in RPA and who had hypotension, managed with inotropes, but succumbed to death. In Case 5, despite high-risk sPESI and RiHT thrombus traversing across a patent foramen ovale into the left atrium, the patient was lysed due to massive PE within 1 h after which he improved.

Mortality rate was 29% (2/7) even after standard management with fibrinolysis, anticoagulants, and surgery. Among the 7 cases, only two had evidence of deep vein thrombosis, as against the usual prevalence of DVT in PE of 70%. Type A RiHT was predominant type 58%, followed by Type B 29% and Type C 13%. Both Deep vein thrombosis cases (cases 1 and 5) had a Type A Raclot. None of the patients had an extension of thrombus into lumen of IVC, except one patient who had thrombus attached to Eustachian valve.

Among 7 patients, 4 were thrombolysed, 2 were treated with anticoagulation alone, and one with surgery. In the fibrinolysis patients, two were better after lysis (50%), and 2 patients (cases 2 and 7) expired (50%).


  Discussion Top


In 1989, the European Working Group on Echocardiography identified three patterns of RiHT.[2] Type A thrombi are morphologically serpiginous, highly mobile and associated with deep vein thrombosis and PE. It is hypothesized that these clots embolize from large veins and are captured in-transit within the right heart.[3],[4] Type B thrombi are nonmobile and are believed to form in situ in association with underlying cardiac abnormalities. Type C thrombi are rare, share a similar appearance to a myxoma and are highly mobile. The prevalence of a right heart thrombus in the setting of an acute pulmonary embolus is 4%–18%.[4] The overall mortality for Type A thrombi is 28%–44%. Thrombolytic agents may dissolve the adherent stalk and actually promote distal embolism of these organized thrombi.[10],[11],[12] Conversely, a prospective case series reported favorable in-hospital survival for patients with Type A thrombi treated with thrombolytics. Bailén et al.[6] described the failure of thrombolysis in two patients with giant right atrial thrombi (presumably Type B or C).

In the European Cooperative Study,[13] mortality rate was reported to be 60% for anticoagulated patients; 40% for those treated with thrombolytics; and 27% for those submitted to surgical procedures, which suggests the surgical approach to the most effective. A meta-analysis study carried out by Kinney and Wright concluded that even showing similar development; heparin should be considered the best option if not faced by imminent, fast clinical deterioration. A more recent meta-analysis study Rose and Punjabi [8] showed global mortality rate to be 27.1%, being 28.6% for those on heparin, 23.8% for those submitted to surgical treatment, 11.3% for those on thrombolytics, and 100% for those not treated. This study studied exclusively embolus in-transit patients probably Type A.

The ICOPER [13] study reported global mortality rate for pulmonary thromboendarterectomy patients with and without thrombus in right chambers to be 21% and 11% within 14 days; 29% and 16% within 3 months, respectively, thus suggesting, in a nonsignificant fashion, the poorer course of patients with intracardiac thrombus. It suggests that patients with intracardiac thrombus should not receive heparin as ideal treatment.

In our series of the RiHT, the association of RiHT and PE are seen in young patients (mean age 31 years) in contrast to the meta-analysis by Rose et al.,[8] which had a mean age of 59 years. They may be due to idiopathic etiology or due to deep vein thrombosis in two cases or associated systemic thromboembolic episodes. Majority in our study were males as opposed to the equal incidence in male and females on the above study. Those with pericardial effusion have either recurrent hospitalization or may prove fatal. Those with high PESI scores have poor prognosis.[14] The overall mortality in our study was 29% in line with meta-analysis by Rose et al. (27%).[8]

Study limitations

Since it is a small case series, the association between the RiHT and the subsequent outcome may not be strong and would require further analysis. This study needs sufficient number of cases for proving the strength of association of the morphology of thrombi in relation to the outcomes. Thrombus assessment by three-dimensional echocardiography and thrombus volume estimation would have given further insight.


  Conclusion Top


Meticulous echo is mandatory in PE. The morphology of right heart thrombus in PE gives additional information regarding the prognosis. Fibrinolysis earlier in the course of the disease in patients with Type A RiHT with massive PE have good prognosis despite the higher rate of mortality with anticoagulants alone. Echo gives valuable information to decide on optimal treatment for a particular scenario.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ferrari E, Benhamou M, Berthier F, Baudouy M. Mobile thrombi of the right heart in pulmonary embolism: Delayed disappearance after thrombolytic reatment. Chest 2005;127:1051-3.  Back to cited text no. 1
    
2.
Kronik G. The European cooperative study on the clinical significance of right heart thrombi. Eur Heart J 1989;10:1046-59.  Back to cited text no. 2
    
3.
Lichodziejewska B, Jankowski K, Kurnicka K, Ciurzynski M, Liszewska-Pfejfer D. A positive outcome in patient with massive acute pulmonary embolism and right atrial mobile thrombus fragmented during thrombolysis: A serial echocardiographic examination. J Intern Med 2005;258:281-4.  Back to cited text no. 3
    
4.
Felner JM, Churchwell AL, Murphy DA. Right atrial thromboemboli: Clinical, echocardiographic and pathophysiologic manifestations. J Am Coll Cardiol 1984;4:1041-51.  Back to cited text no. 4
    
5.
Davutoglu V, Soydinc S, Sezen Y. Complete lysis of left ventricular giant thrombus with fibrinolytic therapy in clopidogrel resistant patient. J Thromb Thrombolysis 2003;15:59-63.  Back to cited text no. 5
    
6.
Bailén MR, Cuadra JA, Aguayo De Hoyos E. Thrombolysis during cardiopulmonary resuscitation in fulminant pulmonary embolism: A review. Crit Care Med 2001;29:2211-9.  Back to cited text no. 6
    
7.
Ruiz-Bailén M, Aguayo-de-Hoyos E, Serrano-Córcoles MC, Díaz-Castellanos MA, Fierro-Rosón JL, Ramos-Cuadra JA, et al. Thrombolysis with recombinant tissue plasminogen activator during cardiopulmonary resuscitation in fulminant pulmonary embolism. A case series. Resuscitation 2001;51:97-101.  Back to cited text no. 7
    
8.
Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest 2002;121:806-14.   Back to cited text no. 8
    
9.
Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: A scientific statement from the American Heart Association. Circulation 2011;123:1788-830.  Back to cited text no. 9
    
10.
Cameron J, Pohlner PG, Stafford EG, O'Brien MF, Bett JH, Murphy AL. Right heart thrombus: Recognition, diagnosis and management. J Am Coll Cardiol 1985;5:1239-43.  Back to cited text no. 10
    
11.
Ruiz-Bailén M, López-Caler C, Castillo-Rivera A, Rucabado-Aguilar L, Ramos Cuadra JA, Lara Toral J, et al. Giant right atrial thrombi treated with thrombolysis. Can J Cardiol 2008;24:312-4.  Back to cited text no. 11
    
12.
Koc M, Kostrubiec M, Meneveau N, Elikowski W, Lankeit M, Grifoni S, et al. Right heart thrombi European registry. JACC 2015;65:A1553.  Back to cited text no. 12
    
13.
Torbicki A, Galié N, Covezzoli A, Rossi 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.  Back to cited text no. 13
    
14.
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.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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