Catheter-Directed Thrombolysis for Giant Right Atrial Thrombus
2010; Lippincott Williams & Wilkins; Volume: 3; Issue: 1 Linguagem: Inglês
10.1161/circimaging.109.906487
ISSN1942-0080
AutoresBradley A. Maron, Samuel Z. Goldhaber, Anthony C. Sturzu, David K. Rhee, Bilal Ali, Pinak Shah, James M. Kirshenbaum,
Tópico(s)Cardiac tumors and thrombi
ResumoHomeCirculation: Cardiovascular ImagingVol. 3, No. 1Catheter-Directed Thrombolysis for Giant Right Atrial Thrombus Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBCatheter-Directed Thrombolysis for Giant Right Atrial Thrombus Bradley A. Maron, MD, Samuel Z. Goldhaber, MD, Anthony C. Sturzu, MD, David K. Rhee, MD, PhD, Bilal S. Ali, MD, Pinak Bipin Shah, MD and James M. Kirshenbaum, MD Bradley A. MaronBradley A. Maron From the Department of Internal Medicine (B.A.M., S.Z.G., B.S.A., P.B.S., J.M.K., D.K.R.), Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; and the Department of Internal Medicine (A.C.S.), Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Mass. , Samuel Z. GoldhaberSamuel Z. Goldhaber From the Department of Internal Medicine (B.A.M., S.Z.G., B.S.A., P.B.S., J.M.K., D.K.R.), Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; and the Department of Internal Medicine (A.C.S.), Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Mass. , Anthony C. SturzuAnthony C. Sturzu From the Department of Internal Medicine (B.A.M., S.Z.G., B.S.A., P.B.S., J.M.K., D.K.R.), Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; and the Department of Internal Medicine (A.C.S.), Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Mass. , David K. RheeDavid K. Rhee From the Department of Internal Medicine (B.A.M., S.Z.G., B.S.A., P.B.S., J.M.K., D.K.R.), Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; and the Department of Internal Medicine (A.C.S.), Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Mass. , Bilal S. AliBilal S. Ali From the Department of Internal Medicine (B.A.M., S.Z.G., B.S.A., P.B.S., J.M.K., D.K.R.), Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; and the Department of Internal Medicine (A.C.S.), Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Mass. , Pinak Bipin ShahPinak Bipin Shah From the Department of Internal Medicine (B.A.M., S.Z.G., B.S.A., P.B.S., J.M.K., D.K.R.), Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; and the Department of Internal Medicine (A.C.S.), Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Mass. and James M. KirshenbaumJames M. Kirshenbaum From the Department of Internal Medicine (B.A.M., S.Z.G., B.S.A., P.B.S., J.M.K., D.K.R.), Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Mass; and the Department of Internal Medicine (A.C.S.), Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Mass. Originally published1 Jan 2010https://doi.org/10.1161/CIRCIMAGING.109.906487Circulation: Cardiovascular Imaging. 2010;3:126–127Giant right atrial thrombus in association with a medical device is rare1,2 but when present poses the threat of massive pulmonary embolism. Surgical resection, catheter embolectomy, and thrombolysis are the principal options for management. We present the case of a 60-year-old man with bilateral pulmonary embolism and a 6-cm right atrial thrombus adherent to an implantable cardioverter-defibrillator (ICD) wire. We treated him successfully with a prolonged intravenous infusion of catheter-directed, low-dose tissue plasminogen activator therapy.Two weeks before admission, he had an acute myocardial infarction and had severely occlusive atherosclerotic coronary disease on coronary angiography. However, a culprit thrombotic lesion to account for the acute myocardial infarction could not be identified. Four days later, the patient survived an in-hospital ventricular fibrillation-induced cardiac arrest, after which an ICD was placed. He was discharged on aspirin 325 mg daily, clopidogrel 75 mg daily, and warfarin 5 mg daily but was nonadherent to this medical regimen.The patient was admitted to our hospital 4 days after prior hospital discharge with a chief complaint of sudden onset of shortness of breath. The physical examination revealed a man in mild distress with a blood pressure of 118/62 mm Hg, heart rate of 103 bpm, respiratory rate of 22 breaths/min, and peripheral blood oxygen saturation level of 95% on 3 L of oxygen per nasal cannula. He had a right ventricular heave and an accentuated pulmonary component of the second heart sound. The patient's Troponin I was elevated, at 0.35 ng/mL. Bedside echocardiography demonstrated a 6�1.5 cm partially recanalized thrombus-in-transit across the tricuspid valve during diastole (FigureA through C; see online-only Data Supplement). Download figureDownload PowerPointFigure. Echocardiographic capture of a giant right atrial thrombus. A, Parasternal long-axis view of the right ventricular inflow tract using bedside 2D transthoracic echocardiography reveals a large, complex thrombus (arrows) adherent to an ICD wire. During diastole the clot traverses from the right atrium (RA) through the tricuspid valve (asterisk) inlet into the right ventricle (RV). B, Transesophageal echocardiography provides enhanced resolution of the clot structure. C, Still image captured during diastole demonstrates full extension (arrows) of the clot that measures approximately 6�1.5 cm. D, Right ventricular inflow tract images acquired by transthoracic echocardiography after the completion of catheter-delivered tissue plasminogen activator (2 mg/h) administered over 24 hours reveal full clot dissolution.Owing to the patient's recent acute myocardial infarction, depressed left ventricular ejection fraction of 35%, elevated pulmonary artery blood pressure (60/35 mm Hg), and remote history of prior coronary artery bypass graft surgery, the on-call surgeon thought that the perioperative risk was insurmountable and declined to perform right atrial thrombectomy. After 3 days without improvement on continuous infusion with intravenous heparin alone, target partial thromboplastin time was 60 to 80 seconds, we proceeded with catheter-directed thrombolysis. The target partial thromboplastin time of intravenous heparin was reduced (50 seconds), and we administered tissue plasminogen activator by continuous infusion (2 mg/h) over 24 hours via a 4F, 11-cm catheter placed fluoroscopically into the mid superior vena cava. This therapy resulted in complete dissolution of the ICD-adherent right atrial clot (FigureD). There were no major bleeding complications, and the patient was discharged home on warfarin therapy without supplemental oxygen after counseling on the critical importance of medication adherence.Prior reports suggest only mixed results with systemically administered thrombolytic therapy.3,4 To the best of our knowledge, this case represents the first report of catheter-directed low-dose thrombolysis for successful treatment of giant right atrial thrombus. We thought that the risk of bleeding associated with a large dose of lytic over a short period of time could be attenuated by catheter-directed low-dose lytic therapy over 24 hours. We placed special attention on the venous catheter placement in the mid superior vena cava, which we confirmed by fluoroscopy, to maximize efficacy and safety. We conclude that one option to consider for the treatment of giant right atrial thrombus is catheter-directed, continuous, prolonged infusion of thrombolysis.The online-only Data Supplement is available at http://circimaging.ahajournals.org/cgi/content/full/3/1/126/DC1.Guest Editor for this article was Gerard Philip Aurigemma, MD.DisclosuresDr Goldhaber is a consultant for Genentech Inc.FootnotesCorrespondence to Bradley Maron, MD, Brigham and Women's Hospital, 75 Francis St, Division of Cardiovascular Medicine, PBB-G, Boston, MA 02115. E-mail [email protected]References1 Kula S, Saygili A, Tunaoglu SF, Olgunturk R. Giant right atrial thrombosis associated with Hickman catheter. Heart. 2003; 89: 1252.CrossrefMedlineGoogle Scholar2 Tonkin JL, Campbell G, Golding L, Hamblin M, Hunter S, Jaggia A. Atrial thrombosis: a near fatal complication of a Portacath. J Vasc Access. 2008; 9: 148–151.CrossrefMedlineGoogle Scholar3 Ruiz-Bailén M, López-Caler C, Castillo-Rivera A, Rucabado-Aguilar L, Ramos Cuadra JA, Lara Toral J, Lozano Cabezas C, Fernández Guerrero JC. Giant right atrial thrombi treated with thrombolysis. Can J Cardiol. 2008; 24: 312–314.CrossrefMedlineGoogle Scholar4 Sokmen G, Sokmen A, Altun B. Free floating right atrial thrombus leading to acute pulmonary embolism. Int J Cardiol. 2008; 129: e12–e14.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Orgeron G, Pollard J, Pourmalek P and Sloane P (2015) Catheter-Directed Low-Dose Tissue Plasminogen Activator for Treatment of Right Atrial Thrombus Caused by a Central Venous Catheter, Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 10.1002/phar.1645, 35:10, (e153-e158), Online publication date: 1-Oct-2015. Dincer H (2012) Right Heart Thrombus, Clinical Pulmonary Medicine, 10.1097/CPM.0b013e31826708a2, 19:5, (226-231), Online publication date: 1-Sep-2012. January 2010Vol 3, Issue 1 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCIMAGING.109.906487PMID: 20086226 Originally publishedJanuary 1, 2010 PDF download Advertisement SubjectsEchocardiographyTreatment
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