P689 Surgical treatment of a right heart thrombus-in-transit with massive bilateral pulmonary embolism

Abstract Introduction Right heart thrombi are rare, found in up to 20% of pulmonary emboli (PE), and associated with significantly increased mortality(1). A thrombus entrapped in a PFO is a rare form of right heart thromboembolism. Clinical Case A 73-year-old male patient who had dyspnea for 10 days, was transferred to our hospital for the surgical treatment of a cardiac tumor. We performed TTE which revealed a free floating, huge mass( measuring more than 8 cm long) in the right atrium, that protruded in the right ventricle, with high risk of embolization. Another smaller mass, attached to the interatrial septum. Severe right ventricular dysfunction and severe pulmonary hypertension were present. Contrast-enhanced computer tomography was performed, which revealed severe bilateral pulmonary artery emboli with complete occlusion of right pulmonary artery branch. Clinical and paraclinical data strongly suggested that the huge cardiac mass was a thrombus that originated from the lower extremity veins. TEE showed that the thrombus was entrapped through the PFO, with a smaller part in the left atrium and the biggest portion in the right atrium. The patient underwent an emergent on-pump surgical cardiac and right pulmonary artery embolectomy. The right atrium was opened and a huge intracardiac thrombus with a lengh of 14 cm extending from the coronary sinus, to PFO in the left atrium and also in the right ventricle was removed. The right branch of the pulmonary artery was opened and a large volume of clot- 9 cm long- was removed. The patient was removed from cardio-pulmonary by-pass (CPB) on high doses of norepinephrine and dobutamine and necessitated initiation of venous-arterial ECMO to support the severe right heart dysfunction. He was extubated after 10 days, with little improvement in the clinical status. Transthoracic echocardiography showed smaller right heart cavities), normal left ventricular function, but persistent severe RV dysfunction and severe pulmonary hypertension. In the thirteenth postoperative day, he installed cardio-respiratory arrest and he died. Discussion In this report we describe a case of a patient with a huge intracardiac thrombus, entrapped through a PFO, associated with massive pulmonary embolism, with late presentation in our hospital and severe refractory right heart dysfunction. He underwent successful embolectomy, which is a unique procedure in the treatment of an acute pulmonary embolism and entrapped thrombus in a PFO. Conclusion The treatment of choice for emboli-in-transit is controversial. In a recent review, surgical thromboembolectomy showed a trend toward improved survival and significantly reduced systemic emboli compared to anticoagulation. Thrombolysis in these patients may cause fragmentation of thrombus and systemic embolization, resulting in increased mortality. Management decisions should be made with multidisciplinary coordination and consideration of complicating factors such as PFO. Abstract P689 Figure. Extensive biatrial thrombus

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Treatment of Mobile Right Heart Thrombi

European Journal of Case Reports in Internal Medicine ◽

10.12890/2020_001918 ◽

2020 ◽

Author(s):

Xenofon M Sakellariou ◽

Andreas Efstathopoulos ◽

Konstantinos V Stamatis ◽

Dimitrios N Nikas ◽

Theofilos M Kolettis

Keyword(s):

Pulmonary Embolism ◽

Pulmonary Artery ◽

Optimal Strategy ◽

Therapeutic Options ◽

Right Heart ◽

Half Dose ◽

Right Pulmonary Artery ◽

The Right

Right heart thrombi are detected in approximately 4% of patients with pulmonary embolism. The associated mortality is high, but the optimal strategy remains controversial. We report a case of a large mobile right heart thrombus, complicated by embolism of the right pulmonary artery, which was successfully treated with half-dose alteplase. We briefly review the literature and discuss the therapeutic options, focusing on the advantages of thrombolysis.

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Unilateral interruption of pulmonary artery with pulmonary hypertension: a case for heart lung transplantation?

Cardiology in the Young ◽

10.1017/s1047951119000271 ◽

2019 ◽

Vol 29 (5) ◽

pp. 704-707 ◽

Cited By ~ 1

Author(s):

Roopesh Singhal

Keyword(s):

Heart Failure ◽

Pulmonary Hypertension ◽

Pulmonary Artery ◽

Lung Transplantation ◽

Congenital Heart ◽

Right Heart Failure ◽

Adverse Outcomes ◽

Severe Pulmonary Hypertension ◽

Right Heart ◽

Right Pulmonary Artery

AbstractUnilateral interruption of pulmonary artery is a rare congenital anomaly which is usually associated with other congenital heart disease. Even more rarely it may occur in isolation. Most of the cases are incidentally detected in adulthood. Some cases develop pulmonary hypertension for yet unknown reasons; such cases usually present in infancy with right heart failure. Surgical correction in such cases is associated with adverse outcomes. Heart lung transplantation should be considered in such patients. We report a 3-year-old boy with interruption of right pulmonary artery with severe pulmonary hypertension and right heart failure who was considered for heart lung transplantation.

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Novel technique of repairing right partial anomalous pulmonary venous connection with intact atrial septum using in situ interatrial septum as a flap in a 68-year-old-woman: a case report

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-020-01313-w ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Atsushi Morishita ◽

Ikuo Hagino ◽

Hideyuki Tomioka ◽

Seiichiro Katahira ◽

Takeshi Hoshino ◽

...

Keyword(s):

Pulmonary Artery ◽

Right Atrium ◽

Septal Defect ◽

Surgical Repair ◽

Interatrial Septum ◽

Pulmonary Artery Hypertension ◽

Right Heart ◽

Intact Atrial Septum ◽

The Right ◽

Anomalous Pulmonary Venous Connection

Abstract Background Partial anomalous pulmonary venous connection draining into the right atrium with an intact atrial septum is a very rare clinical entity in the adult population. Partial anomalous pulmonary venous connection must be suspected as a differential diagnosis when the cause of right heart enlargement and pulmonary artery hypertension is unknown. Case presentation This study describes the surgical case of an isolated right partial anomalous pulmonary venous connection to the right atrium in a 68-year-old woman, who underwent tricuspid ring annuloplasty and right-sided maze procedure simultaneously. She had complaints of gradually progressing dyspnea on exertion. However, a diagnosis could not be established despite consultations at multiple hospitals for over a year. Right heart catheterization revealed severe pulmonary artery hypertension with a mean pulmonary artery pressure of 46 mmHg, step-up phenomenon of oxygen saturation at the mid-level of the right atrium with a pulmonary-to-systemic blood flow ratio of 2.4, and a pulmonary vascular resistance of 3.1 Wood Units. As medical treatment with pulmonary artery vasodilator therapy did not improve her symptoms, she underwent surgical repair. An atrial septal defect was created surgically with a curvilinear tongue-shaped cut. The right anomalous pulmonary veins were rerouted through the surgically created atrial septal defect into the left atrium with a baffle comprised of the interatrial septum flap, kept in continuity with the anterior margin and sutured while mobilizing the enlarged right atrium. The patient had an uneventful postoperative course and remains asymptomatic. Conclusions The described surgical technique could be considered an effective alternative for patients undergoing surgical repair for a partial anomalous pulmonary venous connection isolated to the right atrium. The indication for surgery must be judged on a case-by-case basis in these patients with prevalent systemic-to-pulmonary shunting.

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P701 Usefulness of echocardiography in diagnosis and monitoring in patient with pulmonary embolism during pregnancy, a case report

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.374 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

K Starzyk ◽

P Dybich ◽

K Ciuraszkiewicz ◽

W Rokita ◽

B Wozakowska-Kaplon

Keyword(s):

Pulmonary Embolism ◽

Pulmonary Artery ◽

Troponin T ◽

Pulmonary Arteries ◽

Pulmonary Trunk ◽

Clinical State ◽

Main Trunk ◽

Right Pulmonary Artery ◽

Low Incidence ◽

The Right

Abstract Pulmonary embolism is one of the leading causes of maternal mortality despite a low incidence of during pregnancy. We present 32-year-old woman, in the 35 week of first pregnancy, admitted to the Intensive Care Unit with dyspnea, tachycardia, cyanosis. Echocardiography confirmed the presence of embolic material in the main trunk of pulmonary artery, spreading to the right pulmonary artery. D-dimer and troponin T level were elevated, BNP remained within the normal range. The risk in PESI scale was assumed as intermediate high. LMWH therapy was initiated, the patient was constantly monitored. Venous thrombotic disease in lower extremities was excluded by ultrasonography. The treatment was carried out under obstetric supervision. The clinical state gradually improved, the patient was hemodynamically stable. Serial echocardiographic testing, revealed gradual regression of changes in the pulmonary trunk. Normalization of troponins and lowering of BNP levels were observed. The pregnancy was terminated in 39 week, by cesarean section (obstetric indications). The LMWH was continued few days after delivery, as the patient started lactation. She decided to terminate lactation in a first week after delivery so the therapy was switched into rivaroxaban for at least 3 months. Echocardiography after 3 month confirmed lack of changes in pulmonary trunk, the risk of pulmonary hypertension was low. Echocardiography can be a method of choice for confirming and monitoring pulmonary embolism during pregnancy, in a situation of high or intermediate clinical risk and good visualization of changes in pulmonary arteries Abstract P701 Figure. Embolism of pulmonary trunk and RPA

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Point-of-care Ultrasound Diagnosis of Pulmonary Embolism with Thrombus in Transit

Clinical Practice and Cases in Emergency Medicine ◽

10.5811/cpcem.2018.11.40377 ◽

2019 ◽

Vol 3 (2) ◽

pp. 11-12 ◽

Cited By ~ 2

Author(s):

Nicolas Kahl ◽

Christopher Gabriel ◽

Shadi Lahham ◽

Maxwell Thompson ◽

Wirachin Hoonpongsimanont

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Point Of Care ◽

Skilled Nursing Facility ◽

Point Of Care Ultrasound ◽

Right Heart ◽

Skilled Nursing ◽

Chamber View ◽

The Right ◽

In Transit

A 95-year-old female with a history of dementia and atrial fibrillation (not on anticoagulation) presented to the emergency department (ED) by ambulance from her skilled nursing facility due to hypoxia. Point-of-care ultrasound was performed, and showed evidence of a large mobile thrombus in the right ventricle on apical four-chamber view. Further evidence of associated right heart strain was seen on the corresponding parasternal short-axis view. These ultrasound findings in combination with the patient’s clinical presentation are diagnostic of acute pulmonary embolism with right heart strain. Point-of-care transthoracic cardiac ultrasound in the ED is an effective tool to promptly diagnose acute pulmonary embolism with right heart strain and thrombus in transit and guide further treatment.

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Congenital aneursymal dilatation of the right atrium and co-existent anomalous origin of the right pulmonary artery in a neonatal pig (Sus scrofa)

Veterinary Record ◽

10.1136/vr.144.13.350 ◽

1999 ◽

Vol 144 (13) ◽

pp. 350-351

Author(s):

L. M. Gerlis ◽

A. A. Cunningham

Keyword(s):

Pulmonary Artery ◽

Right Atrium ◽

Sus Scrofa ◽

Anomalous Origin ◽

Right Pulmonary Artery ◽

Neonatal Pig ◽

The Right

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Repair of an Isolated Right Partial Anomalous Pulmonary Venous Connection by Rerouting Blood Flow Through an Interatrial Septum Flap in a 68-Year-Old-Woman: A Case Report

10.21203/rs.3.rs-39603/v1 ◽

2020 ◽

Author(s):

Atsushi Morishtia ◽

Ikuo Hagino ◽

Hideyuki Tomioka ◽

Seiichiro Katahira ◽

Takeshi Hoshino ◽

...

Keyword(s):

Blood Flow ◽

Pulmonary Artery ◽

Right Atrium ◽

Septal Defect ◽

Surgical Repair ◽

Interatrial Septum ◽

Pulmonary Artery Hypertension ◽

Right Heart ◽

The Right ◽

Anomalous Pulmonary Venous Connection

Abstract Background: Partial anomalous pulmonary venous connection draining into the right atrium with an intact atrial septum is a very rare clinical entity in the adult population. Partial anomalous pulmonary venous connection must be suspected as a differential diagnosis when the cause of right heart enlargement and pulmonary artery hypertension is unknown.Case presentation: This study describes the surgical case of an isolated right partial anomalous pulmonary venous connection to the right atrium in a 68-year-old woman, who underwent tricuspid ring annuloplasty and right-sided maze procedure simultaneously. She had complaints of gradually progressing dyspnea on exertion. However, a diagnosis could not be established despite consultations at multiple hospitals for over a year. Right heart catheterization revealed severe pulmonary artery hypertension with a mean pulmonary artery pressure of 46 mmHg, step-up phenomenon of oxygen saturation at the mid-level of the right atrium with a pulmonary-to-systemic blood flow ratio of 2.4, and a pulmonary vascular resistance of 3.1 Wood Units. In addition, it was mandatory to comprehensively utilize valuable imaging modalities, such as transthoracic echocardiography, transesophageal echocardiography, and multidetector computed tomography angiography for the accurate diagnosis and efficient surgical planning of this partial anomalous pulmonary venous connection. As medical treatment with pulmonary artery vasodilator therapy did not improve her symptoms, she underwent surgical repair. An atrial septal defect was created surgically with a curvilinear tongue-shaped cut. The right anomalous pulmonary veins were rerouted through the surgically created atrial septal defect into the left atrium with a baffle comprised of the interatrial septum flap, kept in continuity with the anterior margin and sutured while mobilizing the enlarged right atrium. The patient had an uneventful postoperative course and remains asymptomatic. Conclusions: The described surgical technique could be considered an effective alternative for patients undergoing surgical repair for a partial anomalous pulmonary venous connection isolated to the right atrium. The indication for surgery must be judged on a case-by-case basis in these patients with prevalent systemic-to-pulmonary shunting.

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Transcatheter Removal of Bone Cement Embolism in the Right Atrium after Percutaneous Vertebroplasty: The Embolus Broke in Half and Migrated to the Right Pulmonary Artery Intraoperatively

Journal of the Korean Society of Radiology ◽

10.3348/jksr.2020.0153 ◽

2021 ◽

Vol 82 ◽

Author(s):

Sunhyang Lee ◽

Jae Woo Yeon ◽

Jin-Tae Kwon ◽

Hyuk Jung Kim ◽

Suk Ki Jang

Keyword(s):

Pulmonary Artery ◽

Bone Cement ◽

Right Atrium ◽

Percutaneous Vertebroplasty ◽

Right Pulmonary Artery ◽

Cement Embolism ◽

The Right ◽

Bone Cement Embolism

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Novel technique of repairing right partial anomalous pulmonary venous connection with intact atrial septum using in situ interatrial septum as a flap in a 68-year-old-woman: a case report

10.21203/rs.3.rs-39603/v2 ◽

2020 ◽

Author(s):

Atsushi Morishita ◽

Ikuo Hagino ◽

Hideyuki Tomioka ◽

Seiichiro Katahira ◽

Takeshi Hoshino ◽

...

Keyword(s):

Pulmonary Artery ◽

Right Atrium ◽

Septal Defect ◽

Surgical Repair ◽

Interatrial Septum ◽

Pulmonary Artery Hypertension ◽

Right Heart ◽

Intact Atrial Septum ◽

The Right ◽

Anomalous Pulmonary Venous Connection

Abstract Background: Partial anomalous pulmonary venous connection draining into the right atrium with an intact atrial septum is a very rare clinical entity in the adult population. Partial anomalous pulmonary venous connection must be suspected as a differential diagnosis when the cause of right heart enlargement and pulmonary artery hypertension is unknown.Case presentation: This study describes the surgical case of an isolated right partial anomalous pulmonary venous connection to the right atrium in a 68-year-old woman, who underwent tricuspid ring annuloplasty and right-sided maze procedure simultaneously. She had complaints of gradually progressing dyspnea on exertion. However, a diagnosis could not be established despite consultations at multiple hospitals for over a year. Right heart catheterization revealed severe pulmonary artery hypertension with a mean pulmonary artery pressure of 46 mmHg, step-up phenomenon of oxygen saturation at the mid-level of the right atrium with a pulmonary-to-systemic blood flow ratio of 2.4, and a pulmonary vascular resistance of 3.1 Wood Units. As medical treatment with pulmonary artery vasodilator therapy did not improve her symptoms, she underwent surgical repair. An atrial septal defect was created surgically with a curvilinear tongue-shaped cut. The right anomalous pulmonary veins were rerouted through the surgically created atrial septal defect into the left atrium with a baffle comprised of the interatrial septum flap, kept in continuity with the anterior margin and sutured while mobilizing the enlarged right atrium. The patient had an uneventful postoperative course and remains asymptomatic.Conclusions: The described surgical technique could be considered an effective alternative for patients undergoing surgical repair for a partial anomalous pulmonary venous connection isolated to the right atrium. The indication for surgery must be judged on a case-by-case basis in these patients with prevalent systemic-to-pulmonary shunting.

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