Images and text Genevieve Carbonatto
A 35 year old man presents to the Emergency Department with severe shortness of breath. He is known to have an amphetamine induced cardiomyopathy. His heart rate is 129/min, BP 116/76. He has mild pedal oedema. His JVP is elevated and on auscultation he has crepitations bilaterally.
You decide to do an ECHO to assess his cardiac function and to look for signs of submassive PE. This is his 4 CV.
He has a dilated cardiomyopathy with very poor LV and RV function. Within the RV there appears to be a hyperechoic area, which, with a more dedicated RV view shows a thrombus.
His CXRay is unremarkable and a CTPA is negative for pulmonary embolism. He was anticoagulated and treated for acute pulmonary oedema and transferred to the cardiology ward.
Discussion
The following is from the article in the Canadian Journal of Medicine (1) which discusses the causes of right heart thrombi.
There are 3 patterns of right heart thrombi
- Type A thrombi – morphologically serpiginous, highly mobile and associated with deep vein thrombosis and pulmonary embolism. Predisposing factors include prominent eustachian valves, tricuspid regurgitation, low cardiac output and pulmonary hypertension (8).
- Type B thrombi are nonmobile and are believed to form in situ in association with underlying cardiac abnormalities.
- Type C thrombi are rare, share a similar appearance to a myxoma and are highly mobile.
Prevalence and prognosis
- The prevalence of a right heart thrombus in the setting of an acute pulmonary embolus is 4% to 18% . The overall mortality for type A thrombi is 28% to 44% . A prospective case series reported favourable in-hospital survival for patients with type A thrombi treated with thrombolytics. PE associated with type A thrombus has a 100% mortality without treatment with thrombolytics.
- The prevalence of type B thrombi is unknown, they portend better outcomes than type A thrombi. Caution has been advocated against the use of thrombolytic agents in type B thrombi. Thrombolytic agents may dissolve the adherent stalk and actually promote distal embolism of these organized thrombi.
Our patient did not have a PE on CTPA
Teaching point: RV thrombi are rarely seen in the Emergency Department in our experience. Any patient who is not on anticoagulation and who has a cardiomyopathy should have an ECHO to evaluate cardiac function and to look for thrombi in both ventricles.
References
- Can J Cardiol. 2008 Dec; 24(12): 888.PMCID: PMC2643227 Right heart thrombi: Consider the cause Gordon N Finlayson, MD FRCPC