Early surgical treatment in patients with pulmonary embolism and thrombus-in-transit

Abstract

Background: Floating right heart thrombi (RHT) are in transit from the legs to the pulmonary arteries and thus are a severe form of venous thromboembolism (VTE), with a high early mortality rate without treatment. There is a lack of evidence-based recommendations for its management. The objective of this study is to describe our experience in the surgical management of thrombus-in-transit and pulmonary embolism (PE) in a tertiary hospital.

Methods: We recruited four patients with thrombus-in-transit and PE treated with early surgical embolectomy and anticoagulation. Epidemiologic, laboratory, imaging and clinical data of the thromboembolic episode and the subsequent course were collected.

Results: The sample included 3 males and 1 female, with a mean age of 49.7. The most frequent initial symptoms were dyspnea, syncope, chest pain and signs of deep vein thrombosis (DVT). Transthoracic echocardiogram (TTE) found the thrombus-in-transit in all the cases. The inicial treatment was unfractionated heparin (UFH) and urgent right atriectomy and manual removal of the thrombi. Three patients needed perioperative infusion of vasopressor drugs. All patients had right heart dysfunction at the time of diagnosis. The mean scoring in the Pulmonary Embolism Severity Index (PESI) was 90. All patients survived after 30 days of follow-up.

Conclusions: Early surgical embolectomy of thrombus-in-transit is an effective option of management in selected patients, although the current evidence to support this approach is not definitive.

Keywords: Pulmonary embolism (PE); right heart thrombi (RHT); right heart thrombus in transit (right heart TT); surgical embolectomy.

Figure 1

Computed tomography pulmonary angiography (A,B,C,D): (A) Patient 1. Bilateral PE with extensive filling defect in the bifurcation of the pulmonary trunk (white arrow); (B) patient 2. Bilateral PE with involvement of the trunk both main arteries (white arrow); (C) patient 3. Bilateral PE and thrombus in RV (white arrow); (D) patient 3. Bilateral PE with occupation of both main pulmonary arteries (white arrow) and an area of alveolar hemorrhage due to pulmonary infarction (asterisk). Echocardiogram (E,F,G): (E,F) Patient 2. RV dilated, together with a large thrombus in right atrium (blue arrow) that entered the left atrium (yellow arrow) through a PFO (red arrow) and that was introduced in both ventricles in diastole; (G) patient 3. Presence of a large thrombus in RV (blue arrow). Surgical sample (H,I): thrombus removed from RA and pulmonary trunk by embolectomy in patient 2. PE, pulmonary embolism; RV, right ventricular; PFO, patent foramen ovale; RA, right atrium.