Early surgical treatment in patients with pulmonary embolism and thrombus-in-transit

Abstract

Background: Floating right heart thrombi (RHT) are in transit from the legs to the pulmonary arteries and thus are a severe form of venous thromboembolism (VTE), with a high early mortality rate without treatment. There is a lack of evidence-based recommendations for its management. The objective of this study is to describe our experience in the surgical management of thrombus-in-transit and pulmonary embolism (PE) in a tertiary hospital. Methods: We recruited four patients with thrombus-in-transit and PE treated with early surgical embolectomy and anticoagulation. Epidemiologic, laboratory, imaging and clinical data of the thromboembolic episode and the subsequent course were collected. Results: The sample included 3 males and 1 female, with a mean age of 49.7. The most frequent initial symptoms were dyspnea, syncope, chest pain and signs of deep vein thrombosis (DVT). Transthoracic echocardiogram (TTE) found the thrombus-in-transit in all the cases. The inicial treatment was unfractionated heparin (UFH) and urgent right atriectomy and manual removal of the thrombi. Three patients needed perioperative infusion of vasopressor drugs. All patients had right heart dysfunction at the time of diagnosis. The mean scoring in the Pulmonary Embolism Severity Index (PESI) was 90. All patients survived after 30 days of follow-up. Conclusions: Early surgical embolectomy of thrombus-in-transit is an effective option of management in selected patients, although the current evidence to support this approach is not definitive.

Prevalence, Outcome, and Optimal Management of Free-Floating Right Heart Thrombi in the Context of Pulmonary Embolism, a Systematic Review and Meta-Analysis

“…Moreover, the timing of these procedures seems to have a critical role as most patients who survived surgical thrombectomy had the intervention planned and carried out in the first few hours of presentation. 12 , 51 – 54 Such factors, along with the plethora of evidence supporting the use of thrombolytic therapy in PE, its easy availability, and reduced needs for expertise (compared to surgical thrombectomy or percutaneous thrombectomy) may explain the more established role of thrombolytic therapy in various types of PE as compared to surgical thrombectomy and percutaneous thrombectomy. Interestingly, we found a half-dose (50 mg alteplase) used in a case series of five patients, with excellent outcomes.…”

“…Some reports have suggested that over 90% of FFRHT can end up in PE. 12,21 Furthermore, despite the lack of previous studies documenting the correlation between the hemodynamic consequences and the size of the FFRHT, the latter seems another plausible explanation that warrants further evaluation. Finally, the lack of a clear consensus and guidelines specific to the management of FFRHT in association with PE could have contributed to the dismal outcomes.…”

Tratamiento del tromboembolismo pulmonar y del trombo en tránsito con circulación extracorpórea sin clampeo

“…To conclude, Galeano-Valle et al 1 . reported the surgical management of thrombus-in-transit and pulmonary embolism (PE) in four patients treated with early surgical embolectomy and anticoagulation.…”

“…Due to the complexity of the patients and the lack of randomized studies, we continue debating the best therapy for our patients. Different therapeutic approaches for acute PE with concomitant TT have been reported such as anticoagulation with unfractionated heparin (UFH), systemic thrombolysis with recombinant tissue plasminogen activator (rTPA), surgical embolectomy with exploration of the right chambers, pulmonary arteries under full cardiopulmonary bypass, and endovascular thrombectomy 1 .…”

“…Without treatment, mortality rate is about 90-100%. Right heart thrombi occur in about 4% of pulmonary embolism (PE) 1 .…”