ABSTRACT
SESSION TITLE: Bedside Ultrasound Cases: Beyond Our Sight SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: A thrombus-in-transit (TT), although rare, occurring in approximately 4-18% of pulmonary embolism (PE) cases, carries a high risk of mortality. One study commenting on 80-100% without treatment;therefore, TT should be considered a medical emergency and treated immediately. CASE PRESENTATION: A 64 years old female patient with history of Hypertension and morbid obesity presented to the Emergency department complaining of shortness of breath for 2 weeks with rapid worsening of symptoms and new chest pain in the previous 2 days. Patient blood pressure was 110/70, heart rate 160 irregularly irregular saturating 91% on room air, respiratory rate of 25. Patient tested positive for SARS-CoV-2, and her basic blood work showed elevated BNP and troponin with significant elevation of D-Dimer. The patient never smoked, had no recent travel and not taking OCPs. Bed side point of care echocardiogram showed large right atrial thrombus floating between the right atrium and right ventricle. Subsequent lower extremity ultrasound showed extensive left femoral thrombosis and pulmonary CT Angiogram showed a PE. The treatment options were discussed with the patient including giving full or half dose thrombolytics, or just anticoagulation with heparin. The patient opted for anticoagulation alone. Unfortunately, the patient had a cardiac arrest few hours later. Thrombolytics were given during CPR but the patient passed away. DISCUSSION: TT refers to free-floating right heart thrombi that travel from a venous source in the lower extremities to the pulmonary arteries. Although rare, the presence of a right heart thrombi in the setting of PE predicts a worse prognosis with a high mortality rate and thus, should be treated as a medical emergency. The diagnostic test of choice for TT is an echocardiogram, which shows an elongated right-sided mass illustrating high and chaotic motility with changing shape that continuously prolapses in and out of the right ventricle. Management of TT is still not well established. Options include anticoagulation with heparin, thrombolysis, or surgical removal. A particular study done by Greco et al. in 1999 used recombinant tissue plasminogen activator (rt-PA) with continuous echocardiogram monitoring, that revealed complete lysis of heart clots in all 7 patients within 24 hours. It also showed no changes in symptoms and ultimately showed improvement in blood pressure and heart rate. CONCLUSIONS: Available treatment options include anticoagulation alone, thrombolysis, or surgical embolectomy. Although anticoagulation can prevent clot propagation, it carries a mortality rate of up to 29%, comparable to surgical intervention. Surgical embolectomies could be an alternative option if contraindications to thrombolytics exist. Ultimately, no significant difference was found among the treatment options, suggesting the need for further research and clinical trials. Reference #1: Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and thrombotic or thromboembolic disease: Implications for prevention, antithrombotic therapy, and follow-up: JACC state-of-the-art review. J Am Coll Cardiol. 2020;75(23):2950–73. Reference #2: Cameron, James, et al. "Right Heart Thrombus: Recognition, Diagnosis and Management.” Journal of the American College of Cardiology, vol. 5, no. 5, 1985, pp. 1239–1243., https://doi.org/10.1016/s0735-1097(85)80031-0. Reference #3: Greco, Francesco, et al. "Successful Treatment of Right Heart Thromboemboli with IV Recombinant Tissue-Type Plasminogen Activator during Continuous Echocardiographic Monitoring.” Chest, vol. 116, no. 1, 1999, pp. 78–82., https://doi.org/10.1378/chest.116.1.78. DISCLOSURES: no disclosure on file for Ahmad alkhatatneh;No relevant relationships by Mohammad Alnabulsi No relevant relationships by Mohd Hazem Azzam No relevant relationships by Kelianne Comitalo