Title: Free-Floating Thrombus in Right Heart and Massive Pulmonary Embolism Migrating Into Pulmonary Artery
Abstract: HomeCirculationVol. 111, No. 24Free-Floating Thrombus in Right Heart and Massive Pulmonary Embolism Migrating Into Pulmonary Artery Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBFree-Floating Thrombus in Right Heart and Massive Pulmonary Embolism Migrating Into Pulmonary Artery Yoshihiro Noji, MD, Tohru Kojima, MD, Takahiko Aoyama, MD, Masato Yamaguchi, MD, Tsutomu Araki, MD, Susumu Fujino, MD, Katsuaki Yokota, MD, Noriko Kumamoto, MD, Takakiyo Nakaya, MD, Keiichiro Takase, MD, Masami Shimizu, MD and Hiroshi Mabuchi, MD Yoshihiro NojiYoshihiro Noji From the Department of Cardiology (Y.N., T. Aoyama, M.Y., T. Araki, S.F., K.Y.) and the Department of Respiratory Medicine (T.K., N.K., T.N., K.T.), Fukui Prefectural Hospital, Fukui, and the Molecular Genetics of Cardiovascular Disorders (Y.N., M.S., H.M.), Division of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan. , Tohru KojimaTohru Kojima From the Department of Cardiology (Y.N., T. Aoyama, M.Y., T. Araki, S.F., K.Y.) and the Department of Respiratory Medicine (T.K., N.K., T.N., K.T.), Fukui Prefectural Hospital, Fukui, and the Molecular Genetics of Cardiovascular Disorders (Y.N., M.S., H.M.), Division of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan. , Takahiko AoyamaTakahiko Aoyama From the Department of Cardiology (Y.N., T. Aoyama, M.Y., T. Araki, S.F., K.Y.) and the Department of Respiratory Medicine (T.K., N.K., T.N., K.T.), Fukui Prefectural Hospital, Fukui, and the Molecular Genetics of Cardiovascular Disorders (Y.N., M.S., H.M.), Division of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan. , Masato YamaguchiMasato Yamaguchi From the Department of Cardiology (Y.N., T. Aoyama, M.Y., T. Araki, S.F., K.Y.) and the Department of Respiratory Medicine (T.K., N.K., T.N., K.T.), Fukui Prefectural Hospital, Fukui, and the Molecular Genetics of Cardiovascular Disorders (Y.N., M.S., H.M.), Division of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan. , Tsutomu ArakiTsutomu Araki From the Department of Cardiology (Y.N., T. Aoyama, M.Y., T. Araki, S.F., K.Y.) and the Department of Respiratory Medicine (T.K., N.K., T.N., K.T.), Fukui Prefectural Hospital, Fukui, and the Molecular Genetics of Cardiovascular Disorders (Y.N., M.S., H.M.), Division of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan. , Susumu FujinoSusumu Fujino From the Department of Cardiology (Y.N., T. Aoyama, M.Y., T. Araki, S.F., K.Y.) and the Department of Respiratory Medicine (T.K., N.K., T.N., K.T.), Fukui Prefectural Hospital, Fukui, and the Molecular Genetics of Cardiovascular Disorders (Y.N., M.S., H.M.), Division of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan. , Katsuaki YokotaKatsuaki Yokota From the Department of Cardiology (Y.N., T. Aoyama, M.Y., T. Araki, S.F., K.Y.) and the Department of Respiratory Medicine (T.K., N.K., T.N., K.T.), Fukui Prefectural Hospital, Fukui, and the Molecular Genetics of Cardiovascular Disorders (Y.N., M.S., H.M.), Division of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan. , Noriko KumamotoNoriko Kumamoto From the Department of Cardiology (Y.N., T. Aoyama, M.Y., T. Araki, S.F., K.Y.) and the Department of Respiratory Medicine (T.K., N.K., T.N., K.T.), Fukui Prefectural Hospital, Fukui, and the Molecular Genetics of Cardiovascular Disorders (Y.N., M.S., H.M.), Division of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan. , Takakiyo NakayaTakakiyo Nakaya From the Department of Cardiology (Y.N., T. Aoyama, M.Y., T. Araki, S.F., K.Y.) and the Department of Respiratory Medicine (T.K., N.K., T.N., K.T.), Fukui Prefectural Hospital, Fukui, and the Molecular Genetics of Cardiovascular Disorders (Y.N., M.S., H.M.), Division of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan. , Keiichiro TakaseKeiichiro Takase From the Department of Cardiology (Y.N., T. Aoyama, M.Y., T. Araki, S.F., K.Y.) and the Department of Respiratory Medicine (T.K., N.K., T.N., K.T.), Fukui Prefectural Hospital, Fukui, and the Molecular Genetics of Cardiovascular Disorders (Y.N., M.S., H.M.), Division of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan. , Masami ShimizuMasami Shimizu From the Department of Cardiology (Y.N., T. Aoyama, M.Y., T. Araki, S.F., K.Y.) and the Department of Respiratory Medicine (T.K., N.K., T.N., K.T.), Fukui Prefectural Hospital, Fukui, and the Molecular Genetics of Cardiovascular Disorders (Y.N., M.S., H.M.), Division of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan. and Hiroshi MabuchiHiroshi Mabuchi From the Department of Cardiology (Y.N., T. Aoyama, M.Y., T. Araki, S.F., K.Y.) and the Department of Respiratory Medicine (T.K., N.K., T.N., K.T.), Fukui Prefectural Hospital, Fukui, and the Molecular Genetics of Cardiovascular Disorders (Y.N., M.S., H.M.), Division of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan. Originally published21 Jun 2005https://doi.org/10.1161/CIRCULATIONAHA.104.491340Circulation. 2005;111:e438–e439A 71-year-old man with chronic obstructive pulmonary disease (severe pulmonary emphysema with home oxygen therapy) was referred to our hospital because of 1-day history of dyspnea at rest. His physical examination was remarkable for tachycardia (110 bpm) and tachypnea (32 breaths/min). The ECG demonstrated sinus tachycardia, S waves in leads I and aVL, transition zone to V5, and T-wave inversion in leads III and aVF. A transthoracic echocardiogram (TTE) performed on admission showed that the right atrium and right ventricle were apparently enlarged. The left ventricle had assumed a classic D-shaped configuration, which indicates impaired left ventricular relaxation, and severe tricuspid regurgitation was present. Systolic pulmonary artery pressure of up to 80 mm Hg was estimated on the basis of pulsed Doppler echocardiography. There were no signs of thrombus in the heart. Computed tomography of the chest revealed large thrombi in the right and left pulmonary arteries (Figure 1). The patient received immediate thrombolytic treatment with recombinant tissue plasminogen activator (Monteplase, Eisai Co, Ltd; 1 600 000 U) intravenously, followed by 15 000 U/d unfractionated heparin infusion over a 24-hour period, and both symptoms and pulse oximetry improved initially. Download figureDownload PowerPointFigure 1. Computed tomographic study of thorax showed large thrombi in right (arrows in A) and left (arrows in B) pulmonary arteries.However, on the fifth hospital day, he again became symptomatic, with acute deterioration of pronounced hypoxia. Simultaneous TTE revealed a large wormlike thrombus floating in the right atrium. The thrombus was highly mobile and eventually prolapsed into the right ventricle, then migrated into the pulmonary vasculature. The thrombus took on different shapes during examination (Figure 2). Unfractionated heparin (3000 U IV) was added. TTE repeated after 6 hours showed no signs of thrombus. Computed tomography showed thrombus in the right enlarged popliteal vein. An inferior vena cava filter was placed, and heparin was increased up to 25 000 U/d. His respiratory status had deteriorated, and he required 100% oxygen and then intubation. After that, his condition improved daily, and his trachea was extubated on the 12th hospital day. Heparin was transitioned to warfarin. The patient survived and is currently doing well without surgical embolectomy. Download figureDownload PowerPointFigure 2. Serial TTE. TTE revealed large wormlike thrombus floating in right atrium (arrows in A and B). Thrombus was highly mobile and eventually prolapsed into right ventricle (arrows in C). Both ends of wormlike elongated mass were attached to tricuspid valves (arrows in D), then migrated into pulmonary artery. RA indicates right atrium; RV, right ventricle.Free-floating right heart thrombi are a rare phenomenon. Serial echocardiographic examinations are useful when the clinical status deteriorates, because they may demonstrate thrombus that was not detected on the initial examination.FootnotesReprint requests to Yoshihiro Noji, MD, Department of Cardiology, Fukui Prefectural Hospital, Yotsui 2-8-1, Fukui 910-8526, Japan. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetailsCited By Jalouli I, Mrad M, Fekih-Mrissa N, Hajjej Z, Lebbi A, Labbene I, Gritli N and Ferjani M (2013) Inherited thrombophilia-related complications in the treatment of a biatrial thrombus, Blood Coagulation & Fibrinolysis, 10.1097/MBC.0b013e32835a7323, 24:2, (205-207), Online publication date: 1-Mar-2013. Dincer H (2012) Right Heart Thrombus, Clinical Pulmonary Medicine, 10.1097/CPM.0b013e31826708a2, 19:5, (226-231), Online publication date: 1-Sep-2012. Beiras-Fernandez A, Moehnle P, Kaczmarek I, Weis F, Reichart B and Vicol C (2008) Giant left atrial thrombus with mechanical compromise of the mitral valve, The Journal of Thoracic and Cardiovascular Surgery, 10.1016/j.jtcvs.2007.12.072, 136:5, (1374-1376), Online publication date: 1-Nov-2008. IZUMI M, FUJIWARA R, ONO Y, KUMAGAI F, SATO T, SYOJI A, KUMAGAI H, OSAKA K, KIKUCHI A and KIBIRA S (2008) Thrombus of right ventricular outflow tract in a patient with cerebral infarction, Choonpa Igaku, 10.3179/jjmu.35.19, 35:1, (19-24), . Peláez J, de Miguel E, Moreno R, Gómez L, Etxebeste J, Martín R, de Maeztu Añon J and Salcedo J (2008) Right-atrial floating thrombus attached to the interatrial septum with massive pulmonary embolism diagnosed by echocardiography, International Journal of Cardiology, 10.1016/j.ijcard.2007.06.092, 131:1, (125-127), Online publication date: 1-Dec-2008. Schliamser J and Shiran A (2007) Taenia Cordis, Journal of the American Society of Echocardiography, 10.1016/j.echo.2007.05.011, 20:12, (1418.e9-1418.e11), Online publication date: 1-Dec-2007. June 21, 2005Vol 111, Issue 24 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.104.491340PMID: 15967854 Originally publishedJune 21, 2005 PDF download Advertisement SubjectsAnticoagulantsComputerized Tomography (CT)EchocardiographyImagingPulmonary HypertensionThrombosis