Awab Khan, DO,
Resident Physician
Inspira Medical Center Vineland
Vineland, NJ
Disclosure information not submitted.
Stanley Dumond, MD
Resident Physician
Inspira Health, United States
Disclosure information not submitted.
Hossam Hanna, DO
Resident Physician
Inspira Health Network, United States
Disclosure information not submitted.
Cuiping Li, MD
Resident Physician
Inspira Health Network, United States
Disclosure information not submitted.
Title: A rare case of Right Ventricular Thrombus complicated by Bilateral Pulmonary Emboli
Case Report Body:
Introduction: Anticoagulation (AC) is often required in paroxysmal atrial fibrillation (PAF) to prevent thrombus formation. Medication adherence is essential to this therapeutic effect. Inconsistent dosing can lead to the formation of life-threatening thrombi. Pulmonary emboli (PE) with right heart thrombi (RHT) are rare. The ideal treatment is not known. We present a rare case of bilateral PE caused by RHT.
Description: 79 year-old male with a history of chronic kidney disease, PE and PAF on Rivaroxaban presented with dyspnea. He presented with tachypnea and hypoxia. Physical exam showed a distressed patient with diminished air movement on 2L supplemental oxygen and bilateral lower extremity edema. BNP was elevated. Electrocardiogram was unrevealing. Transthoracic echocardiogram showed a large mobile mass in the RV. RV systolic pressure was estimated at 42mmHg, suggestive of pulmonary hypertension. Heparin infusion was initiated. The mass disappeared on follow-up transesophageal echocardiogram. Ventilation/Perfusion (V/Q) scan showed a high probability of PE with multiple mismatched V/Q defects suggesting embolization. Medical management was continued given the RHT and the risks of manipulations required for thrombectomy. He remained hemodynamically stable with resolution of tachypnea and hypoxia; and was later transitioned to Apixaban for continued AC.
Discussion: RHT is an uncommon condition and medical emergency found in ~ 4% of PE. PE with RHT are associated with higher two-week and three-month mortality. Unfortunately, there is a paucity of well designed randomized controlled trial based literature to support the development of guidelines regarding the optimal management of PE complicated by RHT. The approach is individualized based on the type and size of the thrombus. Treatment options include AC, systemic and catheter directed thrombolysis, and surgical thrombectomy. The available data suggests thrombolysis or surgical thrombectomy may be associated with higher probability of survival in hemodynamically unstable patients compared to AC alone. Thus, aggressive management may be more effective in the management of these patients. Patients with RHT and PE have higher early mortality despite treatment. It is important for clinicians to be aware of the variable presentations of PE as treatment might differ.