Right Atrial Thrombi, the Management Conundrum: 2 Case Reports

Abstract

Case series Patients: Male, 62-year-old • Male, 66-year-old Final Diagnosis: Right atrial floating thrombus • right heart thrombus-in-transit Symptoms: Shortness of breath Medication: — Clinical Procedure: — Specialty: Cardiology Objective: Unusual clinical course Background: There are no guidelines providing an algorithmic approach for the management of right atrial thrombi, to date, owing to a lack of strong supporting studies. In this case series, we describe 2 cases of high-risk patients with massive right atrial thrombi who had different outcomes. Case Reports: Case 1: A 62-year-old man with ischemic cardiomyopathy and atrial fibrillation, who was on a permanent pacemaker for sick sinus syndrome and was noncompliant with medication for 2 years, presented to the Emergency Department for evaluation of a 2-month history of progressive shortness of breath and swollen neck veins. A cardiac ultrasound confirmed a large right atrial thrombus, and a computed tomography (CT) pulmonary angiogram was negative for pulmonary emboli. He was managed with a heparin infusion and thrombolytic therapy with favorable evolution. Case 2: A 66-year-old man, with a past medical history of nonischemic cardiomyopathy, atrial fibrillation, deep venous thrombosis, and pulmonary emboli a year earlier, presented to an urgent care unit with sudden onset of shortness of breath. A cardiac ultrasound confirmed a large right atrial thrombus, and a CT pulmonary angiogram confirmed bilateral pulmonary emboli. He was managed with a heparin infusion and EkoSonic endovascular system therapy. He subsequently needed venoarterial extracorporeal membrane oxygenation for cardiopulmonary resuscitation and underwent mechanical aspiration thrombectomy. The patient’s evolution was unfavorable. Conclusions: In the absence of an evidence-based guideline to approach right atrial thrombi, management should be individualized for each patient, based on the type of thrombi, hemodynamic status, and presence or absence of associated pulmonary emboli.

Catheter related atrial thrombus caused by Abiotrophia defectiva: A case series and review of literature

“…3,4 Type C thrombi are hypermobile, rare, and resemble myxoma 4 and Type B are commonly associated with tunneled dialysis catheters, attached to right atrial wall with significant risk of pulmonary embolization as in our case series. 3,4 A. defectiva is a nutritionally variant viridans streptococci residing in the oral cavity and gut requiring cysteine and pyridoxine enriched medium for growth. 5 It has been implicated in culture negative endocarditis, brain abscess, osteomyelitis, and pulmonary embolism in previous case reports.…”

“…Type A thrombi are highly mobile, serpiginous, and are found in structurally normal atria. 3,4 Type A thrombi are high risk for pulmonary embolism since they are considered as transitory emboli originating from deep vein thrombosis. 3,4 Type C thrombi are hypermobile, rare, and resemble myxoma 4 and Type B are commonly associated with tunneled dialysis catheters, attached to right atrial wall with significant risk of pulmonary embolization as in our case series.…”

“…3,4 Type A thrombi are high risk for pulmonary embolism since they are considered as transitory emboli originating from deep vein thrombosis. 3,4 Type C thrombi are hypermobile, rare, and resemble myxoma 4 and Type B are commonly associated with tunneled dialysis catheters, attached to right atrial wall with significant risk of pulmonary embolization as in our case series. 3,4 A. defectiva is a nutritionally variant viridans streptococci residing in the oral cavity and gut requiring cysteine and pyridoxine enriched medium for growth.…”

Incidental Discovery of a Cardiac Thrombus Mimicking a Right Atrial Myxoma in a Young Female Patient – A Case Report

“…8,25,26 Until this moment, there is no consensus in the specialized literature regarding the best therapeutic approach. 3,22,26,27 In an article written by Chartier et al, concerning a small series of patients diagnosed with free-floating thrombi in the right cardiac chambers, in-hospital mortality was high regardless of the therapeutic strategy. Also, most patients required urgent surgery, and fibrinolysis was only used as a therapeutic bridge in selected cases.…”

“…1,2 There are no guidelines for the management of right atrial thrombi because of the scarcity of studies regarding this condition. 3…”