Chest
Selected ReportsMobile Thrombi of the Right Heart in Pulmonary Embolism: Delayed Disappearance After Thrombolytic Treatment
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.
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2020, Critical Care ClinicsCitation Excerpt :It is thought that CHF promotes stasis within a dilated and hypokinetic right heart entrapping the VTE or encouraging in situ thrombosis instigated by the thrombogenesis of the VTE event.1,10 Studies have also found CIT to be more common among patients with severe PE.7,9,10 It is thought that the elevated pulmonary artery pressures associated with more severe PE create a right to left gradient that halts the VTE as it passes through the heart and prevents it from migrating into the pulmonary vasculature.10,18