Mobile Thrombi of the Right Heart in Pulmonary Embolism: Delayed Disappearance After Thrombolytic Treatment

doi:10.1378/chest.127.3.1051

Chest

Volume 127, Issue 3, March 2005, Pages 1051-1053

https://doi.org/10.1378/chest.127.3.1051 Get rights and content

Background and objective

In patients presenting with pulmonary embolism (PE), echocardiography, in some cases, reveals mobile clots in right heart (RH) cavities. How these clots evolve after treatment, in particular after thrombolytic treatment (TT), is unknown. We sought to determine the outcome of these mobile clots in the RH during TT

Methods and results

Of a series of 343 patients who had been hospitalized for PE in our department, echocardiography performed on hospital admittance showed a mobile clot in the RH in 18 patients (mobile clot incidence, 5.2%). This subgroup of 18 patients presented with a more severe form of PE than the 325 patients without mobile clots in the RH. In our series, 16 patients were treated with thrombolytic agents. Close echocardiography monitoring showed the outcomes of these mobile clots during and after TT. In 50% of cases, the clot disappeared rapidly in < 2 h after the end of TT. In 50% of the remaining cases, the clot disappeared later, half within 12 h following the completion of TT, and the other half within 24 h. All patients were alive on day 30 without any clinical sequellae

Conclusion

In these particular forms of PE with mobile clots in the RH, the short time lag required to disperse the clot after TT makes it imperative to delay any decision about new aggressive therapy

Section snippets

Aim of the Study

The aim of our study was to describe the evolution of RH mobile clots during and after treatment, mainly TT. In particular, we tried to answer the two following questions: (1) What happens to these RH clots during TT?; and (2) Does the disappearance of the RH clots affect the patient's prognosis?

Materials and Methods

Transthoracic echocardiography (TTE) was systematically performed on hospital admission in all patients being hospitalized for PE. In patients with an observed and echocardiographically confirmed RH clot, TTE was repeated at the end of TT, if it had been administered. Subsequently, echocardiography monitoring was done twice a day for 48 h, then once a day until the clot disappeared or whenever a clinical event occurred. The following parameters were gathered: right ventricular size; right

Results

From January 1998 to May 2002, 343 patients were hospitalized for a confirmed PE in our cardiology department. PE was confirmed in 32% of cases using a high-probability lung scan combined with high clinical pretest probability, in 32% of cases by CT scan, and in 5% of cases by angiography. In 31% of cases, PE was diagnosed by the coexistence of confirmed deep venous thrombosis in patients with high clinical pretest probability and nonnegative d-dimer levels. Of these 343 patients, the initial

Discussion

Mobile clots of the RH in patients with PE are now detectable using echocardiography. The incidence of these in-transit mobile clots in the RH is variable, as has been reported in the literature.3, 4 We ourselves reported an incidence of 4% in a French multicenter survey including > 550 patients.5

In an ancillary study using data from the International Cooperative Pulmonary Embolism Registry,6 Torbicki et al2 reported an incidence of 4%, which would decrease to 3.6% if we did not take into

Conclusion

The choice of the optimal treatment for patients with PE presenting with mobile clots in RH is still open to debate. Although this was not the purpose of our study, our series demonstrated favorable results with TT. The short time lag required in 50% of cases to disperse the clot after TT is a new and highly relevant finding. In particular, it suggests that, when a RH clot is still present shortly after TT, we should delay the echocardiogram before deciding on a new aggressive strategy.

References (14)

Z Farfel et al.
Review of echocardiographically diagnosed right heart entrapment of pulmonary emboli-in-transit with emphasis on management
Am Heart J
(1987)
A Torbicki et al.
Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry
J Am Coll Cardiol
(2003)
F Casazza et al.
Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism
Am J Cardiol
(1997)
PS Rose et al.
Treatment of right heart thromboemboli
Chest
(2002)
SZ Goldhaber et al.
Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER)
Lancet
(1999)
EL Kinney et al.
Efficacy of treatment of patients with echocardiographically detected right-sided heart thrombi: a metaanalysis
Am Heart J
(1989)
G Meyer et al.
Effects of intravenous urokinase versus alteplase on total pulmonary resistance in acute massive pulmonary embolism: European multicenter double blind trial; the European Cooperative Study Group for Pulmonary Embolism
J Am Coll Cardiol
(1992)

There are more references available in the full text version of this article.

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Chest

Selected ReportsMobile Thrombi of the Right Heart in Pulmonary Embolism: Delayed Disappearance After Thrombolytic Treatment

Background and objective

Methods and results

Conclusion

Section snippets

Aim of the Study

Materials and Methods

Results

Discussion

Conclusion

Am Heart J

J Am Coll Cardiol

Am J Cardiol

Chest

Lancet

Am Heart J

J Am Coll Cardiol

Selected Reports
Mobile Thrombi of the Right Heart in Pulmonary Embolism: Delayed Disappearance After Thrombolytic Treatment