A 74-year-old female with a past medical history of chronic pulmonary emboli, left ventricular heart failure, and hypertension presented with shortness of breath on exertion and bilateral lower extremity edema for one week. On examination, she was found to have jugular venous distention, crackles in bilateral lung bases, and 3+ pitting peripheral edema. A clinical diagnosis of heart failure was made and she was admitted for diuresis. Echocardiogram showed a severely dilated right ventricle, dilated right atrium, right atrial mass, and an atrial septal secundum defect with bidirectional flow on Doppler. Her right ventricular systolic pressure was estimated at 85 mm Hg with severe right ventricular systolic dysfunction and normal left ventricular function. Patient was started on intravenous diuretics, milrinone, and monitored in the intensive care unit (ICU). A ventilation perfusion scan showed multiple areas of mismatch consistent with acute on chronic pulmonary emboli. Cardiac MRI showed thrombus in the right atrium. PET scan was done to rule out an active cardiac tumor and was negative. Patient did not undergo right heart catheterization due to concern for dislodging the atrial thrombus. She began bosentan treatment for her pulmonary hypertension. Patient was started on a heparin infusion as a bridge to warfarin. Her shortness of breath improved over several days and she was eventually transitioned to the medical floor and discharged shortly after transfer.
Discussion:
Right-sided cardiac thrombi are uncommon and often present a treatment challenge. They are thought to form in deep veins and lodge in the right side of the heart while in transit to the pulmonary vasculature. Available data suggests mortality can be as high as 40% in these cases. There are limited studies to demonstrate the best treatment option for right heart thrombi and no evidence-based guidelines on right-sided thrombi treatment.
Our patient’s presentation was complicated by the presence of her atrial septal defect and the fear that, if manipulated with a catheter, her thrombus would dislodge causing a stroke. Anticoagulation, thrombolysis, and surgery have been debated as right sided cardiac thrombi treatment strategies. In deciding our patient’s therapy, extensive discussion was held between the Cardiology, Pulmonology, Cardiac Surgery, and Interventional Radiology services regarding the safest and best approach to treating our patient’s large thrombus. She was deemed to be a high surgical risk given her acute presentation and co-morbidities and so was treated with anticoagulation. Randomized controlled studies are needed to further delineate the best initial approach, follow up, and long-term treatment for right cardiac thrombi.
Conclusions:
Right-sided thrombi often present a therapeutic dilemma, as data is limited on best approach and outcomes of treatment. Pulmonary hypertension and intracardiac shunts may further complicate acute treatment.