Free floating right atrial thrombus with massive pulmonary embolism:near catastrophic course following thrombolytic therapy

Abstract

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.

The diagnosis of right heart thrombus by focused cardiac ultrasound in a critically ill patient in compensated shock

“…In addition, thrombolysis in patients with PFO increases the risk of fragmentation and paradoxical embolus. There have also been case reports of patients who deteriorated after thrombolysis [ 72 , 86 ] with the suspected mechanism being increased clot burden traveling into the pulmonary vasculature after lysis of thrombus. On the other hand, opting for surgery is not without its risks - waiting time to set up the operating rooms, lack of surgical expertise, anesthesia, cardioplegia, and inability to remove or dissolve distal thrombi.…”

Resolution of a Mobile Right Atrial Thrombus Complicating Acute Pulmonary Embolism With Low-Dose Tissue Plasminogen Activator in a Patient With Recent Craniotomy

“…However, this has not been seen as a complication in prospective studies. 10,12 Intracranial hemorrhage is the most feared complication of thrombolytic therapy, and it has been reported in less than 1% of patients in clinical trials and in 3% of patients in a national registry. 13,14 The randomized and double-blinded Pulmonary Embolism Thrombolysis (PEITHO) trial reported a major bleeding rate of 11.5% and hemorrhagic stroke of 2.0% within 1 week of full-dose tenecteplase.…”

An unusual cause of respiratory failure in a colon cancer patient

“…Giant thrombi (type B) (5), which develop within the heart chambers, are usually fixed, well-organized and fibrotic, intimately associated with the atrial wall and very unlikely to respond to thrombolytic therapy; in fact, in such cases, thrombolytic therapy is often ineffective and unsafe. The few cases of giant atrial thrombi reported in the literature suggest open surgical removal as the procedure of choice (8).…”