BibTex RIS Kaynak Göster

A Free Floating Right Atrial Giant Thrombus Treated by Heparin on the Road to Pulmonary Arteries

Yıl 2013, Cilt: 16 Sayı: 3, 233 - 236, 01.03.2012
https://doi.org/10.5578/kkd.4439

Öz

Free fl oating right atrial thrombi are associated with high mortality. Although trombolysis and surgical trombectomy are recommended, their management is still the subject of debate. A 78 year old woman with a history of stroke a month ago, presented to the emergency department with palpitation. Transthoracic echocardiography revealed a large free-fl oating right atrial thrombus. After intravenous bolus of 5000 IU unfractional heparin she was prepared for cardiac surgery because of contraindications for trombolytic therapy. About 90 minutes after unfractional heparininfusion, we decided to check the thrombus, and realised that it was not there anymore, but there was a slight enlargement in right cardiac chambers. Patient was hemodynamically stabil. Contrast enhanced computerized tomography demonstrated multiple small fi lling defects in the subsegmental branches of pulmonary tree. Surgery was cancelled and Doppler ultrasonography revealed deep venous thrombosis in the left lower limb. After 72 hours of continuous unfractional heparin infusion, warfarin was started. During the hospitalization there was not any complication. Patient was stabil for the following three months. This is a report of free fl oating right atrial trombus origined from deep lower extremity veins and treated by unfractional heparin without any clinical deterioration. In this particular case we think that unfractional heparin might have partly worked because of fresh, unorganised and fragil thrombus. In patients with right atrial free fl oating thrombus, especially when thrombolytic therapy is contraindicated and surgical mortality is high, it may be an alternative to start unfractional heparin and check the thrombus after several hours before the surgery.

Kaynakça

  • Chartier L, Béra J, Delomez M, Asseman P, Beregi JP, Bauchart JJ, et al. Free-fl oating thrombi in the right heart: diagnosis, mana- gement, and prognostic indexes in 38 consecutive patients. Circu- lation 1999;99:2779-83.
  • European Working Group on Echocardiography, The European cooperative study on the clinical signifi cance of right heart throm- bi. European Heart Journal 1989;10:1046-59.
  • Goldhaber SZ. Optimal strategy for diagnosis and treatment of pulmonary embolism due to right atrial thrombus. Mayo Clin Proc 1988;63:1261-4.
  • Panidis IP, Kotler MN, Mintz GS, Ross J. Clinical and echocardiog- raphic features of right atrial masses. Am Heart J 1984;107:745- 58.
  • Rose PS, Punjabi NM, Pearse DB. Treatment of right heart throm- boemboli. Chest 2002;121:806-14.
  • Chapoutot L, Tassigny C, Nazeyrollas P, Poismans P, Maillier B, Maes D, et al. Pulmonary embolism and thrombi of the right heart. Arch Mal Coeur Vaiss 1995;88(Suppl 11):1723-8.
  • Bhargava M, Dincer E. Traveling thrombus in the right atrium: is it the fi nal destination? Pulmonol 2012;2012:378282.
  • Sokmen G, Sokmen A, Yasim A, Oksuz H. Witnessed migration of a giant, free-fl oating thrombus into the right atrium during echo- cardiography, leading to fatal pulmonary embolism. Turk Kardiyol Dern Ars 2009;37:41-3.
  • Mularek-Kubzdela T, Grygier M, Grajek S, Cieśliński A. Right atrial thrombosis-a diffi cult diagnostic and therapeutic problem. Przegl Lek 1997;54:515-9.
  • Pagourelias ED, Fragakis N, Rossios K, Avramidou A, Geleris P. Right atrial thrombus as a complication of supraventricular tach- ycardia ablation resolved by anti-coagulation. Echocardiography 2012; 29:E243-4.
  • Sattiraju S, Masri SC, Liao K, Missov E. Three-dimensional tran- sesophageal echocardiography of a thrombus entrapped by a pa- tent foramen ovale. Ann Thorac Surg 2012;94:e101-2.
  • Kinney EL, Wright RJ. Effi cacy of treatment of patients with ec- hocardiographically detected right-sided heart thrombi: a meta- analysis. Am Heart J 1989;118:569-73.
  • Torbicki A, Galié N, Covezzoli A, Rossi E, De Rosa M, Goldha- ber SZ; ICOPER Study Group. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol 2003;41:2245-51.
  • Ferrari E, Benhamou M, Berthier F, Baudouy M. Mobile thrombi of the right heart in pulmonary embolism: delayed disappearance after thrombolytic treatment. Chest 2005;127:1051-3.
  • Biteker M, Duran NE, Gunduz S, Gokdeniz T, Kaya H, Astarcioglu MA, et al. Comparing different intravenous thrombolytic treatment regimens in patients with prosthetic heart valve thrombosis under the guidance of serial transesophageal echocardiography: a 15- year study in a single center (TROIA Trial). 2008;118:S932.
  • Blendea D, Barrett CD, Heist EK, Ruskin JN, Mansour MC. Right atrial thrombus aspiration guided by intracardiac echocardiog- raphy during catheter ablation for atrial fi brillation. Circ Arrhythm Electrophysiol 2009;2:e18-20.
  • Momose T, Morita T, Misawa T. Percutaneous treatment of a free-fl oating thrombus in the right atrium of a patient with pulmo- nary embolism and acute myocarditis. Cardiovasc Interv Ther 2013;28:188-92.

Pulmoner Artere Doğru Seyri Sırasında Heparin ile Tedavi Edilen Serbest Yüzen Dev Sağ Atriyal Pıhtı

Yıl 2013, Cilt: 16 Sayı: 3, 233 - 236, 01.03.2012
https://doi.org/10.5578/kkd.4439

Öz

Sağ atriyumda serbest yüzen pıhtı, yüksek mortaliteyle seyreder. Trombolitik tedavi ve cerrahi trombektomi önerilse de, yönetimi halen tartışma konusudur. Bir ay önce inme öyküsü olan 78 yaşında kadın hasta acil servise çarpıntı şikayetiyle başvurdu. Transtorasik ekokardiyografi yle sağ atriyum içerisinde serbest yüzen büyük bir pıhtı saptandı. Trombolitik tedavi açısından kontrendikasyonları olması sebebiyle 5000 IU intravenöz anfraksiyone heparin bolus yapılarak cerrahi trombektomi hazırlıklarına başlandı. Heparin bolusundan yaklaşık 90 dakika sonra pıhtıyı transtorasik ekokardiyografi yle tekrar kontrol ettiğimizde, artık yerinde olmadığını gördük fakat sağ kalp boşluklarında hafi f bir genişleme vardı. Hasta hemodinamik olarak stabildi. Kontrastlı toraks bilgisayarlı tomografi tetkikinde subsegmental pulmoner arter dallarında çok sayıda küçük dolum defektleri izlendi. Ameliyat iptal edildi ve Doppler ultrasonografi de sol alt ekstremitede derin ven trombozu saptandı. Yetmiş iki saatlik heparin infüzyonunu takiben warfarin başlandı. Hastanede yatış süresince herhangi bir komplikasyon gelişmedi. Hasta takip eden üç ay boyunca stabildi. Sağ atriyal serbest yüzen pıhtısı olan bu hastada unfraksiyone heparinin kısmen işe yaraması, pıhtının taze, organize olmamış ve kırılgan yapısından kaynaklanıyor olabilir. Sağ atriyal serbest yüzen pıhtısı olan hastalarda, özellikle trombolitik tedavi kontrendikeyse ve cerrahi mortalite yüksekse, cerrahi öncesinde anfraksiyone heparin tedavisine başlamak ve birkaç saat sonra pıhtıyı kontrol etmek alternatif olabilir.

Kaynakça

  • Chartier L, Béra J, Delomez M, Asseman P, Beregi JP, Bauchart JJ, et al. Free-fl oating thrombi in the right heart: diagnosis, mana- gement, and prognostic indexes in 38 consecutive patients. Circu- lation 1999;99:2779-83.
  • European Working Group on Echocardiography, The European cooperative study on the clinical signifi cance of right heart throm- bi. European Heart Journal 1989;10:1046-59.
  • Goldhaber SZ. Optimal strategy for diagnosis and treatment of pulmonary embolism due to right atrial thrombus. Mayo Clin Proc 1988;63:1261-4.
  • Panidis IP, Kotler MN, Mintz GS, Ross J. Clinical and echocardiog- raphic features of right atrial masses. Am Heart J 1984;107:745- 58.
  • Rose PS, Punjabi NM, Pearse DB. Treatment of right heart throm- boemboli. Chest 2002;121:806-14.
  • Chapoutot L, Tassigny C, Nazeyrollas P, Poismans P, Maillier B, Maes D, et al. Pulmonary embolism and thrombi of the right heart. Arch Mal Coeur Vaiss 1995;88(Suppl 11):1723-8.
  • Bhargava M, Dincer E. Traveling thrombus in the right atrium: is it the fi nal destination? Pulmonol 2012;2012:378282.
  • Sokmen G, Sokmen A, Yasim A, Oksuz H. Witnessed migration of a giant, free-fl oating thrombus into the right atrium during echo- cardiography, leading to fatal pulmonary embolism. Turk Kardiyol Dern Ars 2009;37:41-3.
  • Mularek-Kubzdela T, Grygier M, Grajek S, Cieśliński A. Right atrial thrombosis-a diffi cult diagnostic and therapeutic problem. Przegl Lek 1997;54:515-9.
  • Pagourelias ED, Fragakis N, Rossios K, Avramidou A, Geleris P. Right atrial thrombus as a complication of supraventricular tach- ycardia ablation resolved by anti-coagulation. Echocardiography 2012; 29:E243-4.
  • Sattiraju S, Masri SC, Liao K, Missov E. Three-dimensional tran- sesophageal echocardiography of a thrombus entrapped by a pa- tent foramen ovale. Ann Thorac Surg 2012;94:e101-2.
  • Kinney EL, Wright RJ. Effi cacy of treatment of patients with ec- hocardiographically detected right-sided heart thrombi: a meta- analysis. Am Heart J 1989;118:569-73.
  • Torbicki A, Galié N, Covezzoli A, Rossi E, De Rosa M, Goldha- ber SZ; ICOPER Study Group. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol 2003;41:2245-51.
  • Ferrari E, Benhamou M, Berthier F, Baudouy M. Mobile thrombi of the right heart in pulmonary embolism: delayed disappearance after thrombolytic treatment. Chest 2005;127:1051-3.
  • Biteker M, Duran NE, Gunduz S, Gokdeniz T, Kaya H, Astarcioglu MA, et al. Comparing different intravenous thrombolytic treatment regimens in patients with prosthetic heart valve thrombosis under the guidance of serial transesophageal echocardiography: a 15- year study in a single center (TROIA Trial). 2008;118:S932.
  • Blendea D, Barrett CD, Heist EK, Ruskin JN, Mansour MC. Right atrial thrombus aspiration guided by intracardiac echocardiog- raphy during catheter ablation for atrial fi brillation. Circ Arrhythm Electrophysiol 2009;2:e18-20.
  • Momose T, Morita T, Misawa T. Percutaneous treatment of a free-fl oating thrombus in the right atrium of a patient with pulmo- nary embolism and acute myocarditis. Cardiovasc Interv Ther 2013;28:188-92.
Toplam 17 adet kaynakça vardır.

Ayrıntılar

Birincil Dil Türkçe
Bölüm Makaleler
Yazarlar

Evrin Dağtekin Bu kişi benim

Çağdaş Akgüllü Bu kişi benim

Ufuk Eryılmaz Bu kişi benim

Yayımlanma Tarihi 1 Mart 2012
Yayımlandığı Sayı Yıl 2013 Cilt: 16 Sayı: 3

Kaynak Göster

APA Dağtekin, E. ., Akgüllü, Ç. ., & Eryılmaz, U. . (2012). Pulmoner Artere Doğru Seyri Sırasında Heparin ile Tedavi Edilen Serbest Yüzen Dev Sağ Atriyal Pıhtı. Koşuyolu Kalp Dergisi, 16(3), 233-236. https://doi.org/10.5578/kkd.4439
AMA Dağtekin E, Akgüllü Ç, Eryılmaz U. Pulmoner Artere Doğru Seyri Sırasında Heparin ile Tedavi Edilen Serbest Yüzen Dev Sağ Atriyal Pıhtı. Koşuyolu Kalp Dergisi. Mart 2012;16(3):233-236. doi:10.5578/kkd.4439
Chicago Dağtekin, Evrin, Çağdaş Akgüllü, ve Ufuk Eryılmaz. “Pulmoner Artere Doğru Seyri Sırasında Heparin Ile Tedavi Edilen Serbest Yüzen Dev Sağ Atriyal Pıhtı”. Koşuyolu Kalp Dergisi 16, sy. 3 (Mart 2012): 233-36. https://doi.org/10.5578/kkd.4439.
EndNote Dağtekin E, Akgüllü Ç, Eryılmaz U (01 Mart 2012) Pulmoner Artere Doğru Seyri Sırasında Heparin ile Tedavi Edilen Serbest Yüzen Dev Sağ Atriyal Pıhtı. Koşuyolu Kalp Dergisi 16 3 233–236.
IEEE E. . Dağtekin, Ç. . Akgüllü, ve U. . Eryılmaz, “Pulmoner Artere Doğru Seyri Sırasında Heparin ile Tedavi Edilen Serbest Yüzen Dev Sağ Atriyal Pıhtı”, Koşuyolu Kalp Dergisi, c. 16, sy. 3, ss. 233–236, 2012, doi: 10.5578/kkd.4439.
ISNAD Dağtekin, Evrin vd. “Pulmoner Artere Doğru Seyri Sırasında Heparin Ile Tedavi Edilen Serbest Yüzen Dev Sağ Atriyal Pıhtı”. Koşuyolu Kalp Dergisi 16/3 (Mart 2012), 233-236. https://doi.org/10.5578/kkd.4439.
JAMA Dağtekin E, Akgüllü Ç, Eryılmaz U. Pulmoner Artere Doğru Seyri Sırasında Heparin ile Tedavi Edilen Serbest Yüzen Dev Sağ Atriyal Pıhtı. Koşuyolu Kalp Dergisi. 2012;16:233–236.
MLA Dağtekin, Evrin vd. “Pulmoner Artere Doğru Seyri Sırasında Heparin Ile Tedavi Edilen Serbest Yüzen Dev Sağ Atriyal Pıhtı”. Koşuyolu Kalp Dergisi, c. 16, sy. 3, 2012, ss. 233-6, doi:10.5578/kkd.4439.
Vancouver Dağtekin E, Akgüllü Ç, Eryılmaz U. Pulmoner Artere Doğru Seyri Sırasında Heparin ile Tedavi Edilen Serbest Yüzen Dev Sağ Atriyal Pıhtı. Koşuyolu Kalp Dergisi. 2012;16(3):233-6.