Right Heart Thrombi: Patient Outcomes by Treatment Modality and Predictors of Mortality: A Pooled Analysis

Abstract

Rationale: Right heart thrombi (RiHT) is characterized by the presence of thrombus within the right atrium or right ventricle (RV). Current literature suggests pulmonary embolism (PE) with RiHT carries a high mortality. Guidelines lack recommendations in managing RiHT. We created a pooled analysis on RiHT and report on our institutional experience in managing RiHT. We aimed to evaluate whether patient characteristics and differing treatment modalities predict mortality. Methods: We created a pooled analysis of case reports and series of patients with RiHT and PE between January 1956 and 2017. We also reviewed a series of consecutive patients with RiHT identified from our institutional PE registry. Age, shock, RV dysfunction, clot mobility, treatment modality, and hospital outcome had to be reported. Results: We identified 316 patients in our pooled analysis. Patients received the following therapies: no treatment 15 (5%), systemic anticoagulation 73 (23%), systemic thrombolysis 108 (34%), surgical embolectomy 101 (32%), catheter-directed therapy 11 (3%), and systemic thrombolysis with surgery 8 (3%). In-hospital mortality was 18.7%. Univariate analysis showed age and shock reduced odds of survival. Multivariate analysis showed shock reduced odds of survival (odds ratios [OR] 0.36, 95% confidence interval [CI]: 0.19-0.72, P ≤ .01) while age, RV dysfunction, and clot-mobility did not affect mortality. In a reduced multivariate analysis adjusting for shock, treatment modality, and clot location alone, systemic thrombolysis increased odds of survival when compared to systemic anticoagulation (OR 2.72, 95% CI: 1.11-6.64, P = .02). Our institutional series identified 18 patients, where in-hospital mortality was 22.2%, 18 (100%) had RV dysfunction, and 5 (28%) had shock. Patients received the following therapies: systemic anticoagulation 8 (44.4%), systemic thrombolysis 4 (22.2%), surgical embolectomy 4 (22.2%), and catheter-directed thrombolysis 2 (11.1%). Conclusion: Presence of shock in RiHT is an independent predictor of mortality. Systemic thrombolysis may offer increased odds of survival when compared to systemic anticoagulation. Our findings should be interpreted with caution as they derive from retrospective reports and subject to publication bias.

Pulmonary Embolism With Clot in Transit: An Analysis of Risk Factors and Outcomes

“…We found a 30-day all-cause mortality rate of 24.3%. This is in line with most studies on CIT, which report mortalities ranging between 19% and 34% (Akilli et al 2013;Cassaza et al 1997;Islam et al 2018;Kinney et al 1989;Koć et al 2016;Rose et al 2002;Torbicki et al 2003). Moreover, our mortality rate was significantly increased compared to PE positive patients without CIT (24.3% vs 9.7%, P < 0.001).…”

“…Our data support this with 45.5% of CIT patients who died by 7 days presenting with hemodynamic collapse compared 12.3% of CIT patients who did not die (P = 0.018). In agreement with Islam et al (2018), echocardiographic RV dysfunction was not associated with mortality by 7 days within CIT patients.…”

“…Therefore, mental status change could reflect risk for mortality in CIT patients. Islam et al (2018) did not find an association between altered mental status and in hospital mortality in CIT patients (4% vs 8%, P = 0.1354), however these results were obtained via a pooled analysis and are likely limited by incomplete reporting of data.…”

“…However, we suspect that the patients who died were: a) too unstable to undergo a CTPA to diagnose the PE, or b) visualization of the CIT on echocardiogram was considered sufficient for a diagnosis of PE. Finally, Islam et al (2018) and Koć et al (2016) have suggested that the high mortality associated with CIT can be attributed to hemodynamic consequences. Our data support this with 45.5% of CIT patients who died by 7 days presenting with hemodynamic collapse compared 12.3% of CIT patients who did not die (P = 0.018).…”

Catheter-directed thrombolysis for thrombi in right atrium and upper extremity caused by peripherally inserted central catheters

“…After consultation with a cardiac surgeon who considered the patient's overall condition, the patient was not recommended to undergo cardiac surgery. Although previous reports indicate that surgery could remove the blood clots, [12,15] surgical trauma is massive and more difficult. 3.…”