Project description:Acute pulmonary embolism (PE) is the third most common cause of cardiovascular death in Europe. The presence of a floating thrombus in the right sections, is a life-threatening condition in which the most appropriate treatment is not well established. The management of this setting is still uncertain, particularly in cases of thrombosis straddling the patent foramen ovale (PFO). The stratification and treatment of PE do not consider the presence of intracardiac floating thrombosis. We describe the case of a female, 69-years-old, presenting to the emergency department because of sudden onset of dyspnea and pre-syncope. An echocardiogram was performed, showing a massive floating thrombus both in the right and left atrium, passing through a PFO. The patient underwent systemic thrombolysis with alteplase. After 1 h of infusion, sudden onset of left facio-brachio-crural hemiplegia occurred. An urgent cerebral angiographic computed tomography was performed with evidence of acute occlusion of the right M1 branch treated with mechanical thrombectomy. The presence of intracardiac thrombosis in both right and left cardiac chambers with involvement of the fossa ovalis added a further level of management complexity. To date, no clear therapeutic strategies are recommended in these clinical settings.Learning objective•The presence of floating thrombosis in the right sections is a life-threatening condition and could be considered in the risk stratification of pulmonary embolism•The presence of intracardiac thrombosis straddling the foramen ovale is a condition that poses additional difficulties in choosing the correct therapeutic approach during massive pulmonary embolis.
Project description:A 28-year-old policeman presented with left lower limb deep vein thrombus, pulmonary embolism and a highly mobile right atrial clot. Thrombolytic therapy with IV Tenecteplase was administered. Within a few minutes after the Tenecteplase bolus, the patient's condition worsened dramatically with severe hypotension and hypoxemia. Immediate bedside transthoracic echocardiogram revealed that the mobile right atrium clot had disappeared completely presumably having migrated to the pulmonary circulation thus worsening the clinical condition. With intensive supportive measures the patient's condition was stabilized and he made a complete recovery. Prior to discharge, the echocardiogram revealed normal right ventricular function and a CT pulmonary angiogram performed after 2 months revealed near complete resolution of pulmonary thrombi. Thrombolytic therapy for right heart thrombus with pulmonary embolism can be a reasonable first line therapy but may be associated with hemodynamic worsening due to clot migration.
Project description: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.
Project description:Pulmonary vein thrombosis (PVT) is a rare but life-threatening clinical condition, often found incidentally on imaging. In this report, we present an interesting case of PVT of the left inferior pulmonary vein with extension into the left atrium in a 78-year-old woman presenting with "jolts" in the chest. Initial imaging with plain chest film radiograph showed findings consistent with COPD and no acute intrathoracic process. A CT angiogram of the chest revealed a filling defect consistent with thrombus within the left inferior pulmonary vein extending into the left atrium. A transthoracic echocardiogram was remarkable for a severely enlarged right ventricular cavity with moderately reduced right ventricular systolic function and normal left ventricular size with preserved systolic function. She was not a candidate for any surgical interventions, and she was managed with systemic anticoagulation. Management of PVT mostly depends on the underlying cause as there are no well-defined treatment guidelines. The consensus recommends systemic anticoagulation until thrombus resolution. When anticoagulation is contraindicated, thrombectomy is indicated to restore blood flow. In patients with similar presentation and clinical history it is important to consider PVT, and to focus on prompt diagnosis and early initiation of appropriate treatment.