Ann Thorac Surg 2007;84:2104-2106. doi:10.1016/j.athoracsur.2007.06.015
© 2007 The Society of Thoracic Surgeons
Case Reports
Pulmonary Thromboembolism With Floating Thrombus Trapped in Patent Foramen Ovale
Thomas Theologou, MS, MRCSa,
Prabhat Tewari, MDb,
Kate Pointon, MRCP, FRCRc,
Ian M. Mitchell, MD, FRCSd,*
a Department of Cardiac Surgery, Trent Cardiac Centre, Nottingham University Hospital NHS Trust, City Hospital Campus, Nottinghamshire, United Kingdom
b Department of Cardiac Anesthesia, Trent Cardiac Centre, Nottingham University Hospital NHS Trust, City Hospital Campus, Nottinghamshire, United Kingdom
c Department of Radiology, Trent Cardiac Centre, Nottingham University Hospital NHS Trust, City Hospital Campus, Nottinghamshire, United Kingdom
d Department of Trent Cardiac Centre, Nottingham University Hospital NHS Trust, City Hospital Campus, Nottinghamshire, United Kingdom
Accepted for publication June 5, 2007.
* Address correspondence to Dr Mitchell, Trent Cardiac Centre, Nottingham University Hospital NHS Trust, City Hospital Campus, Hucknall Road, Nottinghamshire, NG5 1PB, United Kingdom (Email: ian.mitchell{at}nuh.nhs.uk).
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Abstract
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A 39-year-old man was hospitalized with symptoms of acute deep vein thrombosis, and computed tomography showed that he had pulmonary thromboembolism. Transthoracic echocardiography showed a large, right atrial thrombus and transesophageal echocardiography showed migrating thrombus trapped in a patent foramen ovale and extending all the way up to the ascending aorta. He underwent surgical embolectomy under cardiopulmonary bypass. At the conclusion of the operation, repeat transesophageal echocardiography examination revealed fresh but small thrombus in the right atrium. This continued entry of thrombi into the heart was further managed with fluoroscopy-guided insertion of a retrievable inferior vena cava filter through the internal jugular vein in the operating room itself.
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Introduction
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Deep vein thrombosis resulting in pulmonary thromboembolism (PE) carries a high risk, but it can be a preventable cause of mortality. Currently, the treatment options include systemic anticoagulation, vena cava filters, thrombolytic therapy, percutaneous thrombectomy, and surgical embolectomy. We describe a patient who had to undergo surgical embolectomy and inferior vena cava (IVC) filter insertion for PE after deep vein thrombosis.
A young 39-year-old man was admitted into the emergency room with shortness of breath, cough, fever, an edematous right painful calf, chest pain, significant hypoxia, and cardiovascular instability. There was a past history of recurrent leg swelling suggestive of previous deep vein thrombosis. A spiral computed tomographic scan revealed the diagnosis of a straddling thrombus at the bifurcation of the pulmonary artery and some thrombi in distal branches of the pulmonary artery (Fig 1). Transthoracic echocardiography showed a thrombus going across the patent foramen ovale (PFO) into the left atrium and the left ventricle. The patient was treated with systemic heparin infusion, but urgent surgical embolectomy with closure of the PFO under cardiopulmonary bypass using bi-caval cannulation and cold cardioplegic heart arrest was planned. Intraoperative transesophageal echocardiography confirmed the findings of a transthoracic echocardiography and showed the migrating embolus across the PFO, which was also seen in the left ventricle, the left ventricular outflow tract, and the aortic valve, and it fluttered into the ascending aorta (Figs 2, 3).
The right ventricle was dilated and had poor contractility. The right atrium was overloaded and showed severe regurgitation across the tricuspid valve, which indicated severe pulmonary hypertension.
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Fig 2. Transesophageal echocardiography midesophageal aortic short-axis view showing a long wormlike free-floating thrombus entrapped in a patent foramen ovale (PFO). (LA = left atrium; RA = right atrium; RV = right ventricle.)
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Fig 3. Transesophageal echocardiography midesophageal long-axis view showing the free-floating thrombus in the left atrium (LA) and going across the mitral valve into the left ventricle (LV) and left ventricular outflow tract (LVOT). (IVS = intraventricular septum; RVOT = right ventricular outflow tract.)
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During the procedure the right atrium was opened and the migrating thrombus across the PFO was pulled out and the PFO was surgically closed. The main pulmonary artery was opened and the straddling thrombus was removed. Finally, the left atrium and the aorta were opened to confirm that no remnant thrombus remained. The patient was separated from cardiopulmonary bypass with minimal inotropic support. Postoperative cardiopulmonary bypass transesophageal echocardiography showed a fresh thrombus in the right atrium (Fig 4). An interventional radiologist inserted a retrievable IVC filter (Günther Tulip IVC Filter, [Cook Inc, Bloomington, IN]) through the superior vena cava under fluoroscopic guidance at the completion of surgery in the operating room. The patient fully recovered and was discharged home on warfarin and aspirin with advice to a have hematological follow-up.
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Fig 4. Transesophageal echocardiography midesophageal view with probe rotated to the right so as to center the right atrium (RA). A new free-floating thrombus in the RA is seen. (LA = left atrium; RV = right ventricle.)
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Comment
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The incidence of deep vein thrombosis in the general population is nearly 1 in 5,000. It is almost nonexistent for those who are less than 20 years of age, and its incidence increases with age [1]. Many patients have underlying inherited predisposition to hypercoagulability, such as factor V Leiden, Behçet’s disease, paroxysmal nocturnal hemoglobinuria, deficiency of factor C, S, and antithrombin III, which can present with deep vein thrombosis. One third of patients with venous thromboembolism can present with PE and have a mortality of approximately 12% [2]. Floating right heart thrombi are uncommon and are always associated with acute PE. Paradoxical movement of the thrombus across a PFO indicates reversal of flow from the right atrium to the left atrium due to acute PE. Floating right heart thrombi are said to be mostly long and wormlike arising from the leg veins [3]. Transthoracic echocardiography is one of the quickest ways to diagnose these thrombi, but transesophageal echocardiography can give additional information about the flow across a PFO, showing thrombus in the pulmonary artery or showing the thrombus straddled across a PFO [4]. These floating right heart thrombi are at risk of fragmenting and giving rise to systemic emboli. Therefore, they require emergency surgical evacuation [5]. After surgical evacuation of the floating right heart thrombi, acute migration of new thrombi can occur in the immediate postoperative period. We elected for the insertion of an IVC filter, as we had past experience with a similar case resulting in postoperative death in the intensive care unit due to recurrence of pulmonary thromboembolism. The subsequent transesophageal echocardiography finding of a free thrombus in the right atrium of our patient while the chest was being closed in the operation room supported our decision.
Classical indications of the use of IVC filters have been the contraindication to anticoagulation, failure of anticoagulation, complications of anticoagulation, and a predisposition to PE. There have been reports for adjunctive IVC filter use in patients undergoing pulmonary embolectomy for massive PE [6], but data is lacking in the setting of immediate postoperative embolectomy. Long-term complications of IVC filter placement include malposition, migration, vena cava occlusion, and perforation, and they have been found to occur more frequently than in patients who were treated with anticoagulation alone [7]. However, in the same trial the 12-day incidence of PE was less in the filter group making a case for the use of a retrievable IVC filter for a more aggressive approach to preventing the recurrance of PE in the immediate postoperative period.
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References
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- Fowkes FJ, Price JF, Fowkes FG. Incidence of diagnosed deep vein thrombosis in the general population: systematic review Eur J Vasc Endovasc Surg 2003;25:1-5.[Medline]
- White RH. The epidemiology of venous thromboembolism Circulation 2003;17:I4-I8107(23 Suppl 1).
- Panidis IP, Kotler MN, Mintz GS, Ross J. Clinical and echocardiographic features of right atrial masses Am Heart J 1984;107:745-758.[Medline]
- Nelessen U, Daniel WG, Matheis G, Oelert H, Depping K, Lichtlen PR. Impending paradoxical embolism from atrial thrombus: correct diagnosis by transesophageal echocardiography and prevention by surgery J Am Coll Cardiol 1985;5:1002-1004.[Abstract]
- Chapoutot L, Nazeyrollas P, Metz D, et al. Floating right heart thrombi and pulmonary embolism: diagnosis, outcome and therapeutic management Cardiology 1996;87:169-174.[Medline]
- Greenfield LJ, Proctor MC, Williams DM, et al. A long term experience with transvenous catheter pulmonary embolectomy J Vasc Surg 1993;18:450-457.[Medline]
- Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena cava filters in prevention of pulmonary embolism in patient with proximal deep-vein thrombosis N Engl J Med 1998;338:409-415.[Abstract/Free Full Text]
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Abstract
Introduction
