A Proposed Approach for the Management of Clot-in-Transit.

Clot-in-transit (CIT) is defined as a mobile echogenic material in the right atrium or ventricle as observed on ultrasound. A right heart free-floating thrombus is unusual when there is no structural disease of the heart or atrial fibrillation. Cardiopulmonary collapse and quick death can come from CIT, which occurs when a blood clot moves from the heart to the lungs. There are some clinical case reports of a large volume thrombus that was freely floating in the right heart in an asymptomatic patient, and the best therapeutic options are uncertain. Although several trials have been conducted on the treatment of CIT, clinical judgment is still used to determine the best treatment for right heart thrombus (RHT), especially when associated with pulmonary embolism (PE). In this review article, we discuss various diagnostic modalities and treatment options for this rare malady. We studied in detail their clinical impact on patients according to past research studies.

Point-of-care ultrasound assessment with handheld ultrasound device attached to cell phone.

Recent advances in ultrasound technology have made modern handheld ultrasound devices and are contributing to make bedside ultrasound evaluation a practice available to all physicians. A 46-year-old woman with history of systemic erythematosus presented to our hospital with 14 days of COVID-19. The patient suddenly presented greater respiratory distress, tachycardia, hypotension, and increased supplemental oxygen requirements; so she required mechanical ventilation. Point-of-care ultrasound assessment with handheld ultrasound device was observed on the apical view an apical thrombus in the right ventricle, McConnell's sign. The patient underwent systemic thrombolysis with alteplase showing improvement in mechanical ventilation parameters and is currently continuing treatment for COVID-19 in the intensive care unit of our hospital. Emerging technologies such as handheld ultrasound devices can provide high-quality care to the patients. Routine screening of patients with COVID-19 using handheld ultrasound is feasible, may be able to define prognosis and treatment of cardiovascular complications.

Saddle pulmonary embolism and clot in transit in COVID-19 infection: a case report of catastrophic venous thromboembolism.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is associated with a coagulopathy favouring thrombosis over bleeding that imparts a poor prognosis. Clot in transit (CIT) is considered a rare entity and the most severe form of venous thromboembolism (VTE), carrying a higher mortality than isolated pulmonary embolism (PE). The incidence of this phenomenon in patients with COVID-19 infection is unknown and likely under-recognized. CASE SUMMARY: During the peak of the COVID-19 pandemic in New York City, a 70-year-old Hispanic female presented with syncope due to a saddle PE further complicated by a highly mobile CIT. Polymerase chain reaction was positive for COVID-19 infection, however, there was no evidence of lung parenchymal involvement or hyper-inflammation. Based on consensus from a multidisciplinary team, aspiration thrombectomy was attempted to treat this extreme case of VTE, however, the patient died during the procedure. DISCUSSION: This case raises awareness to the most catastrophic form of VTE, presenting in an early phase of COVID-19 infection without the typical hyper-inflammation and severe lung injury associated with development of COVID-related coagulopathy. It also serves to inform on the critical role echocardiography has in the comprehensive evaluation and re-evaluation of hospitalized patients with COVID-19, and the importance of a multidisciplinary organized approach in clinical decision-making for this complex and poorly understood disease and its sequelae.

Right Ventricular Clot in Transit in COVID-19: Implications for the Pulmonary Embolism Response Team.

Severe acute respiratory syndrome coronavirus 2 is associated with a prothrombotic state in infected patients. After presenting a case of right ventricular thrombus in a patient with coronavirus disease-2019 (COVID-19), we discuss the unique challenges in the evaluation and treatment of COVID-19 patients, highlighting our COVID-19-modified pulmonary embolism response team algorithm. (Level of Difficulty: Beginner.).