Clinical and echocardiographic diagnosis, follow up and management of right-sided cardiac thrombi

Abstract

Background: Right-sided cardiac masses are infrequent and have varied clinical presentation. The present study describes the clinical features, echocardiographic findings and management of 19 patients presenting with right-sided cardiac thrombi in a tertiary care center in north India.

Methods: This is a retrospective, single center observational study of consecutive patients over the period January 2003-2008 admitted in our emergency intensive care unit (EICU). We identified 38 patients with right-sided cardiac masses admitted to EICU diagnosed by transthoracic echocardiography of which 19 patients had right-sided thrombus. The echocardiographic findings were reviewed by two cardiologists in all patients. Treatment was not standardized and choice of therapy was based on judgment of attending physician.

Results: The mean age of patients with cardiac thrombus was 36.6 ± 11.8 years. Right atrial (n = 17) and right ventricle (n = 2) thrombi were associated with deep vein thrombosis (DVT) in 7 (36.8%) and pulmonary embolism in 3 (15%) patients. 13 (68.4%) patients appeared to have in situ mural thrombus. 12 patients were managed with oral anticoagulants, 3 patients underwent surgery and 4 patients were thrombolysed. All the survivors had a mean follow-up of 40 ± 6 months (range--18-50 months).

Conclusions: Prompt echocardiographic examination in an appropriate clinical setting facilitates faster diagnosis and management of patients with right-sided cardiac thrombi. High incidence of in situ mural thrombus and varied comorbidities predisposing to right-sided cardiac thrombi besides DVT and pulmonary embolism need to be recognized. Oral anticoagulation and thrombolysis appear to be the mainstay of treatment with surgery limited for selected patients.

Keywords: ASD; ATT; BMV; CA; CABG; CCP; CTEPH; Cardiac; DVT; EICU; ELISA; Echocardiography; HIV; IV; IVC; LA; LV; MI; MVR; Oral anticoagulation; PA; PAH; PASP; PFO; RA; RV; RVOT; Right atrium; STK; TEE; Thrombolysis; Thrombus; VQ; antitubercular treatment; atrial septal defect; balloon mitral valvotomy; carcinoma; chronic constrictive pericarditis; chronic thromboembolic pulmonary hypertension; coronary artery bypass grafting; deep vein thrombosis; emergency intensive care unit; enzyme linked immunosorbent assay; human immunodeficiency virus; inferior vena cava; intravenous; left atrial; left ventricle; mitral valve replacement; myocardial infarction; patent foramen ovale; pulmonary arterial hypertension; pulmonary artery; pulmonary artery systolic pressure; recombinant tissue plasminogen activator; right atrial; right ventricle; right ventricle outflow tract; rtPA; streptokinase; trans-esophageal echocardiography; ventilation perfusion.

Fig. 1

Fig. 2

Flow chart depicting imaging characteristics of right-sided masses and the treatment strategy.

Fig. 3

TTE image (sub costal view) showing round well circumscribed heterogenous mass attached to inter atrial septum in a seven day old new born.

Fig. 4

TEE (bicaval view) showing oval homogenous mass with translucency at periphery. Mass was immobile below RA appendage in a patient of severe mitral stenosis, PAH with severe RV systolic dysfunction.

Fig. 5

TEE (bicaval view) showing irregular mobile sea anemone like mass in protruding in right atrium in a patient of constrictive pericarditis.

Fig. 6

TEE image (four chamber view) showing vermicular mass moving across mitral value via PFO in a patient of tubercular pneumonia and DVT.