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

Abstract

Right heart thrombus in transit (RHTT) is a rare, severe form of venous thromboembolism that carries a high mortality rate. The optimal treatment for RHTT has not been well established. Thrombolysis is a therapeutic modality for RHTT but carries the risk of bleeding complications including intracranial hemorrhage. Low-dose thrombolysis has been shown to be effective in treating submassive pulmonary emboli without an increased risk in bleeding complications, but it has not been studied in patients with RHTT. Here, we discuss the case of a 74-year-old male with lung cancer and recent craniotomy with metastasectomy 30 days prior to admission presenting with RHTT and bilateral pulmonary emboli (PE). He was treated successfully with low-dose thrombolysis, despite his relative contraindication to thrombolytics. To our knowledge, this is the first reported case of low-dose alteplase (tissue plasminogen activator [tPA]) used to treat an in-transit PE in the setting of recent craniotomy with metastasectomy.

Thrombolysis of Postoperative Acute Pulmonary Embolism with a Thrombus in Transit

“…In general, right heart thrombus in the setting of PE is uncommon. ere are previous existing case reports of using half-dose thrombolysis to successfully treat an in-transit clot with complete resolution [22,23]. A recent study comparing the efficacy of different treatment modalities for right heart thrombi in transit reported thrombolysis was more effective than anticoagulation alone for improving survival without any additional complication risks [24].…”

Rescue thrombolysis partial failure in massive PE complicated with in-transit thrombus

“…Greco et al5 evaluated thrombus behavior during administration of alteplase by two-dimensional echocardiogram; they reported the lysis occurred with a progressive fragmentation in little particles that move from the heart chambers to pulmonary arteries to eventually disappear. However, when reviewing the available literature, it seems that it is unclear whether the disappearance of right heart thrombosis following thrombolytic treatment is due to complete dissolving of the thrombus or migration to the pulmonary circulation 11…”

Clot In Transit in a Patient with Protein S Deficiency

“…It can be seen in 3% of patients with pulmonary embolism (PE), and up to 18% of those with massive PE. Mortality rates are between 80% and 100% in those with untreated CIT, and far higher in patients with PE and CIT than in those without CIT [ 1 , 2 ] . Interestingly, it is unclear whether CIT is a marker of disease severity or contributes to mortality by itself [ 2 ] .…”

“…Mortality rates are between 80% and 100% in those with untreated CIT, and far higher in patients with PE and CIT than in those without CIT [ 1 , 2 ] . Interestingly, it is unclear whether CIT is a marker of disease severity or contributes to mortality by itself [ 2 ] . Clot characteristics such as attachment, mobility and location are not associated with changes in mortality [ 1 ] .…”