Right Heart Thrombus Associated With Extensive DVT And PE

Proposal Number:

MCC-7144 

Proposal Type:

Medically Challenging Case Report Poster 

Author:

Andrea Farela  
Resident at cleveland clinic florida

Co-Author(s):

Luis Santiago  
Cleveland Clinic Florida
Matthew Huertas  
FAU-cleveland clinic florida

Abstract:

Learning Objectives:
1. Describe etiologies for right heart thrombus.
2. Learn about therapeutic options for right heart thrombus.
3. Identify differential diagnosis for right heart thrombus.

Thrombus in the right heart is a rare ocurrence, especially in the absence of atrial fibrillation, structural heart disease or catheters in-situ. Right heart thrombi have a considerable prevalence in patients with pulmonary embolism and carry a significant mortality if therapy not instituted early.
Therapeutic options in these patients consist of anticoagulation, thrombolysis or surgical embolectomy, but the optimal management remains controversial.

A 32 year old female with PMH of asthma, DM type 2 and GERD presented to our institution with a history of approximately 2 months of SOB, pain in the right neck and chest pain mainly at exertion which would worsen on deep inspiration. TEE revealed right ventricular mass that appeared to start at the base of the tricuspid valve and encroach on the right ventricular outflow tract. A CT scan of the chest reported pulmonary emboli in the left lower lobe and pleural effusion, as well as a thick rind of thrombus adherent to the right lateral wall of the right atrium. She also presented with eosinophilia. She was started on anticoagulation therapy and transferred to our institution for further evaluation and management. On the basis of the large right ventricular mass and inability to obtain a biopsy, with accompanying worsening of symptoms and decreased right ventricular function, the decision was made to perform excision of the mass under cardiopulmonary bypass (CPB). Frozen section revealed chronic thrombus. The patient had a fairly uncomplicated hospital course and was discharged home on postoperative day 7 on full anticoagulation with warfarin and enoxaparin.

In this particular case, initial workup suggested primary cardiac mass or Loeffler endocarditis, which is what triggered a surgical intervention vs other therapy

Professional Category:

Resident/Trainee

Keywords:

Cardiothoracic

Enter up to two references.

  Reference
1. 1. Finlayson GN. Right heart thrombi: consider the cause. Can J Cardiol. 2008 Dec;24(12):888. PubMed PMID: 19068540; PubMed Central PMCID: PMC2643227.
2. 2. Rose, Peter S. et al.Treatment of Right Heart Thromboemboli. CHEST, Volume 121, Issue 3, 806 - 814