Intracardiac thrombus extending from the right atrium to the left ventricle in patient presenting with pulmonary embolism

Mullusoge Mariappa Harsha; Santhosh Krishnappa; Kanchanahalli Siddegowda Sadananda; Manjunath Cholenahally Nanjappa

doi:10.4103/JICC.JICC_11_20

CASE REPORT

Year : 2020 | Volume : 10 | Issue : 3 | Page : 145-147

Intracardiac thrombus extending from the right atrium to the left ventricle in patient presenting with pulmonary embolism

Mullusoge Mariappa Harsha, Santhosh Krishnappa, Kanchanahalli Siddegowda Sadananda, Manjunath Cholenahally Nanjappa
Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Science and Research, Mysore, Karnataka, India

Date of Submission	17-Mar-2020
Date of Decision	10-Jun-2020
Date of Acceptance	10-Jun-2020
Date of Web Publication	23-Dec-2020

Correspondence Address:
Dr. Mullusoge Mariappa Harsha
Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Mysore Branch, K.R.S Road, Mysore, Karnataka
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JICC.JICC_11_20

Abstract

Thrombus in transit straddling foramen ovale with impending systemic embolization is a rare event. Most cases are reported during the evaluation of stroke. Such thrombus in patients presenting with pulmonary embolism is extremely rare. We report such a rare case with large thrombus extending from the right atrium to left atrium through patent foramen ovale, prolapsing across mitral valve up to mid left ventricle.

Keywords: Deep vein thrombosis, pulmonary embolism, stroke, thrombus-in-transit

How to cite this article:
Harsha MM, Krishnappa S, Sadananda KS, Nanjappa MC. Intracardiac thrombus extending from the right atrium to the left ventricle in patient presenting with pulmonary embolism. J Indian coll cardiol 2020;10:145-7

How to cite this URL:
Harsha MM, Krishnappa S, Sadananda KS, Nanjappa MC. Intracardiac thrombus extending from the right atrium to the left ventricle in patient presenting with pulmonary embolism. J Indian coll cardiol [serial online] 2020 [cited 2021 Jan 24];10:145-7. Available from: https://www.joicc.org/text.asp?2020/10/3/145/304371

Introduction

Thrombus in transit from the right atrium to left atrium straddling patent foramen ovale (PFO) with impending systemic embolization is a rare event. Usually, such thrombi are small, seeping through foramen ovale, and transiently visualized during the evaluation of stroke. We report a rare case of large thrombus extending from the right atrium through foramen ovale to the left atrium prolapsing across the mitral valve, in patient presenting with acute pulmonary embolism (PE).

Case Report

A 54-year-old male patient with a history of the right lower limb swelling for 1 week presented with breathlessness New York Heart Association III of 2 days duration. There is no history of syncope. On clinical examination, pulse rate (PR) was 110/min, blood pressure 104 / 70 mmHg, resting respiratory rate of 22/min, SpO2 94% on room air, and with right lower limb swelling. Cardiovascular system examination revealed tachycardia with right ventricle (RV) S3. The respiratory system was normal, the abdomen was soft with no focal neurological deficits. Electrocardiogram revealed S1Q3T3 pattern with T-wave inversion in V2-V6. Hemogram, creatinine, and thyroid-stimulating hormone were normal. Troponin was positive.

Two-dimensional echocardiogram showed normal left ventricular systolic function, dilated right atrium, RV, RV dysfunction with the tricuspid annular plane systolic excursion 15 mm, McConnell's sign, moderate tricuspid regurgitation, and severe pulmonary hypertension with RV systolic pressure of 74 mmHg. Echogenic structure likely thrombus was visualized in the right atrium and the left atrium, straddling PFO, prolapsing across mitral valve extending up to mid left ventricle [Figure 1] and Video 1. The same was confirmed with a transesophageal echocardiogram. A single large thrombus was extending from the right atrium to left atrium through PFO; prolapsing each diastole across mitral valve extending up to mid left ventricle [Figure 2] and Video 2. Computed tomography pulmonary angiogram showed PE involving left pulmonary artery and bilateral segmental branches. Furthermore, thrombus was noticed in the right atrium and left atrium across the interatrial septum [Figure 3]. Lower limb venous Doppler revealed right-sided deep vein thrombus extending up to iliac veins. This patient was referred to for emergency surgery in view of associated left heart thrombus for thrombus removal plus pulmonary embolectomy.

Figure 1: Dilated right atrium and ventricle with thrombus in (a) Right and left atrium; (b) left ventricle; (c) Across interatrial septum; (d) Prolapsing across the mitral valve

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Figure 2: (a-c) Transesophageal echocardiogram showing thrombus at different angles (d) Continuous Doppler across the tricuspid valve

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Figure 3: (a) Electrocardiogram with S1Q3T3 with inversion V2-V6; computed tomography scan demonstrating (b) Pulmonary embolism, (c) Right atrial thrombus attached to interatrial septum, (d) Left atrial and right atrial thrombus

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Discussion

Embolization of deep vein thrombosis leads to PE. A PFO puts the patient at risk for paradoxical embolism. Current guidelines suggest that patients with acute PE with hypotension are treated with thrombolytic therapy. Clinical deterioration that has not resulted in hypotension may also prompt the use of thrombolytic therapy.^[1],[2] Right heart thrombi occur in about 4% of PE,^[3] is associated with a significantly higher mortality rate of about 28% in treated patients and 80%–100% in untreated patients.^[4] In contrast, the in-hospital mortality rate for acute PE is about 2.5%.^[3]

Patent foramen ovale is a hemodynamically insignificant interatrial communication present in >25% of the adult population responsible for a subset of cryptogenic stroke.^[5] There are case reports demonstrating venous thrombi trapped in a PFO in patients with central or systemic embolization.^[6],[7] Usually, such thrombi are small, seeping through foramen ovale, transiently visualized during the evaluation of stroke. Studies have shown improved survival with surgical embolectomy as compared to anticoagulation alone in patients who are hemodynamically stable with low-to-moderate surgical risk.^[7],[8] The presence of such thrombus in patients presenting with PE has therapeutic implications.^[9] Thrombolysis being contraindicated, this patient was referred for the surgery for thrombus removal with pulmonary embolectomy. Anticoagulation alone may not suffice in view of large left heart mobile thrombus with a high risk of systemic embolization.

This case is unique as this is the first case being reported where the thrombus is extending from the right atrium up to the left ventricle in patient with PE. There are no reported cases till date to the best of our knowledge. Furthermore, thrombus straddling PFO in patient presenting with PE is extremely rare, narrowing down therapeutic options to high-risk surgery or anticoagulation alone. Disease rarity results in a lack of standardized treatment guidelines.

Conclusion

All patients with PE should be looked for thrombus in transit across PFO given its therapeutic implications.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

We thank Miss Veena, ECHO technician for her help.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Kearon C, Akl EA, Omelas J, Blaivas A, Jimenez D, Bounameaux H, et al. Antithrombotic therapy for VTE disease: CHEST Guideline and expert panel report. Chest 2016;149:315-52.
2.	Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020;41:543-603.
3.	Carson JL, Kelley MA, Duff A, Weg JG, Fulkerson WJ, Palevsky HI, et al. The clinical course of pulmonary embolism. N Engl J Med 1992;326:1240-5.
4.	Athappan G, Sengodan P, Chacko P, Gandhi S. Comparative efficacy of different modalities for treatment of right heart thrombi in transit: A pooled analysis. Vasc Med 2015;20:131-8.
5.	Shunichi H, Ralph LS. Patent foramen ovale and stroke. Circulation 2005;112:1063-72.
6.	Hust MH, Staiger M, Braun B. Migration of paradoxic embolus through a patent foramen ovale diagnosed by echocardiography: Successful thrombolysis. Am Heart J 1995;129:620-2.
7.	Baydoun H, Barakat I, Hatem E, Chalhoub M, Mroueh A. Thrombus in transit through patent foramen ovale. Case Rep Cardiol 2013;2013:395879.
8.	Fauveau E, Cohen A, Bonnet N, Gacem K, Lardoux H. Surgical or medical treatment for thrombus straddling the patent foramen ovale: Impending paradoxical embolism? Report of four clinical cases and literature review. Arch Cardiovas Dis 2008;101:637-44.
9.	Shepherd F, White-Stern A, Rahaman O, Kurian D, Simon K. Saddle pulmonary embolism with thrombus in transit across a patent foramen ovale. Case Rep Cardiol 2017;2017:6752709.