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LETTER TO EDITOR Table of Contents   
Year : 2010  |  Volume : 13  |  Issue : 2  |  Page : 178-179
Catastrophic course of free floating right heart thrombus in elective surgery


Department of Anaesthesia & Intensive Care, Aga Khan University, P.O. Box 3500, Stadium Road, Karachi - 74800, Pakistan

Click here for correspondence address and email

Date of Web Publication3-May-2010
 

How to cite this article:
Samad K, Khan MF, Qureshi R, Hoda M Q, Ullah H. Catastrophic course of free floating right heart thrombus in elective surgery. Ann Card Anaesth 2010;13:178-9

How to cite this URL:
Samad K, Khan MF, Qureshi R, Hoda M Q, Ullah H. Catastrophic course of free floating right heart thrombus in elective surgery. Ann Card Anaesth [serial online] 2010 [cited 2022 Jun 28];13:178-9. Available from: https://www.annals.in/text.asp?2010/13/2/178/62940


The Editor,

Free-floating right heart thrombus is a rare phenomenon. Though the actual incidence is unknown, echocardiographic studies in patients with pulmonary embolism show an incidence of 7 to 18%. [1] They can embolize at any time and may result in an emergent situation requiring rapid and appropriate management. Such events result in high mortality rate (greater than 40 %). [1]

Case: The patient was a 55-year-old morbidly obese female, presented with a compressed fracture of the 11 th and 12 th thoracic vertebrae, following a motor vehicle accident two weeks earlier. She was bed-ridden due to the pain since the accident. She was scheduled for elective pedicle screw fixation of the vertebra and her pre-operative evaluation did not reveal any significant abnormality. The surgery was conducted in prone position and the intra-operative course was unremarkable. At the end of the procedure, she was turned supine and, soon after neuromuscular blockade reversal, she developed asystolic cardiac arrest. The patient was successfully reverted following resuscitation. Invasive hemodynamic monitoring was established (arterial and central venous line), intravenous infusion of adrenaline and dopamine was started to maintain hemodynamic stability. Chest X-ray and other laboratory investigation conducted at that time were normal. She was shifted to the intensive care unit (ICU). A transthoracic echocardiogram showed dilated right-sided cardiac chambers with moderate tricuspid regurgitation and a mass attached to the right atrium close to the tricuspid valve causing obstruction. A diagnosis of pulmonary embolism secondary to the free floating right heart thrombus was made. The cardiothoracic consult was sought and an emergency surgical embolectomy was planned. During the course, she suffered two episodes of cardiac arrest of short duration (two and four minutes) from which she was successfully resuscitated. By open heart surgery, large clots were removed from the right atrium and pulmonary artery [Figure 1]. Upon completion of the surgery, attempts to wean the patient from cardiopulmonary bypass were unsuccessful. On direct visualization, the contractile function of the heart was very poor despite high inotropic support. After discussion with family, it was decided to hold all attempts of resuscitation and the patient was declared dead.

For patients with a mobile right heart thrombus, the incidence of pulmonary embolism is 97% and reported mortality is over 44%. [1],[2] Although it is associated with a high mortality, ther is no clarity on its managament. [1] The role of embolectomy versus thrombolysis in clinically stable patients is still controversial. [3] Surgical embolectomy with exploration of the right heart chambers and pulmonary arteries under cardiopulmonary bypass is the preferred treatment in hemodynamically unstable patients. [1] Patients with poly trauma have an increased risk of deep venous thrombosis. Factors independently associated with an increased risk of venous thromboembolism are spinal cord injury, lower extremity or pelvic fracture, increasing age, and prolonged immobility. [4] All patients with trauma having one or more risk factors for thromboembolism should receive thromboprophylaxis. The key to successful management lies in early diagnosis and prompt treatment. [5] This case report is published to bring to light the possibility of adverse outcomes in patients with pulmonary thromboembolism despite the described aggressive treatment.

 
   References Top

1.Chartier L, Bιra J, Delomez M, Asseman P, Beregi JP, Bauchart JJ, et al. Free-floating thrombi in the right heart: Diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation 1999;99:2779-83.   Back to cited text no. 1      
2.Ferrari E, Benhamou M, Berthier F, Baudouy M. Mobile thrombi of the right heart in pulmonary embolism: Delayed disappearance after thrombolytic treatment. Chest 2005;127:1051-3.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Greco F, Bisignani G, Serafini O, Guzzo D, Stingone A, Plastina F. Successful treatment of right heart thromboemboli with IV recombinant tissue-type plasminogen activator during continuous echocardiographic monitoring: A case series report. Chest 1999;116:78-82.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.Farfel Z, Shechter M, Vered Z, Rath S, Goor D, Gafni J. Review of echocardiographically diagnosed right heart entrapment of pulmonary emboli-in-transit with emphasis on management. Am Heart J 1987;113:171-8.  Back to cited text no. 4  [PUBMED]    
5.Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2005;127:2297-8.  Back to cited text no. 5      

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Correspondence Address:
Muhammad Faisal Khan
Department of Anaesthesia & Intensive Care, Aga Khan University, P.O. Box 3500, Stadium Road, Karachi - 74800
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.62940

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This article has been cited by
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