Right Atrial Thrombus: A Hanging Question

1Yale‐New Haven Hospital, New Haven, CT
2Yale School of Medicine, New Haven, CT

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 308

Case Presentation:

A 34‐year‐old woman with a stage IV infiltrative ductal breast carcinoma being treated with capecitabine and goserelin was admitted for management of a right atrial thrombus incidentally found on restaging contrast‐enhanced computerized tomography (CT) 4 days prior to admission. Results showed a possible defect in the inferior vena cava concerning for thrombus without evidence of pulmonary emboli (PE). On the day of admission, the patient underwent an echocardiogram that showed a mobile echodensity in the right atrium that appeared to originate from the IVC. The echodensity was noted to move to and fro across the tricuspid valve. Right ventricular function was normal. On evaluation, she denied any chest pain, shortness of breath, leg pain,z or swelling. On exam she was an obese woman who was breathing comfortably. Cardiac examination demonstrated a regular rhythm with no murmurs, gallops, or plops. There was no lower‐extremity swelling or calf tenderness. She had no indwelling lines. Blood work revealed a troponin < 0.01 ng/mL and pro‐B‐type natriuretic peptide of 17 pg/mL. There was no right heart strain on electrocardiogram. Bilateral lower‐extremity ultrasound examination was without thrombus.

Discussion:

Right heart thromboemboli (RHTE), often referred to as “thrombi‐in‐transit,” represent a rare form of venous thromboembolic disease (VTE). Presentation can vary from hemodynamic instability to an insidious onset, as was the case with this patient. RHTE are most often discovered by echocardiogram done during the evaluation of PE. Management options include anticoagulation alone, thrombolysis, interventional percutaneous thrombus retrieval, or surgical thrombectomy. As this is a rare clinical event, no randomized trials are available, and there is no consensus on the ideal treatment option. Case series have shown conflicting results with significant mortality between 20% and 60% regardless of the treatment chosen. In this case, a multidisciplinary approach was employed with consultants from hematology, thoracic surgery, interventional radiology, and pulmonology. As the patient was stable with good cardiopulmonary reserve, anticoagulation alone was chosen with a low threshold to provide thrombolytics if clinical deterioration occurred. On hospital day 4, the patient complained of a brief episode of left‐sided pleuritic chest pain that resolved spontaneously. Her vitals remained stable. On hospital day 7, a repeat echocardiogram showed no evidence of thrombus. A PE protocol CT chest prior to discharge confirmed a PE in the distal left pulmonary artery and posterior basal right lower lobe. The patient was discharged in stable condition on low‐molecular‐weight heparin.

Conclusions:

RHTE represent a rare and potentially life‐threatening form of VTE. This case highlights the importance of a multidisciplinary approach when facing rare clinical situations so that therapy can be tailored.

To cite this abstract:

Apgar S, Hoimes C. Right Atrial Thrombus: A Hanging Question. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 308. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/right-atrial-thrombus-a-hanging-question/. Accessed May 22, 2019.

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