5
T&H Images
A four-chamber in transit heart thrombus in a pregnant woman with
acute pulmonary embolism
Franco Casazza1; Carla Caponi2; Serena Mignoli2
1Division
of Cardiology, San Carlo Borromeo Hospital, Milan, Italy; 2Division of Internal Medicine, Valli del Noce Hospital, Cles (TN), Italy
A 32-year-old pregnant woman, at week
25, was admitted for acute chest pain. On
physical examination, arterial blood pressure was 120/80 mm Hg, and respiratory
rate was 26/minute (min). Arterial blood
gas measurements were: PaO2= 75 mm Hg,
PaCO2= 26 mmHg, pH=7.47. High-sensitivity troponin T was 16 pg/ml (reference
value< 14 pg/ml). The electrocardiogram
showed sinus tachycardia 110/min and
negative T-waves in anterior leads. Lowerlimb ultrasound documented a left femoropopliteal deep-vein thrombosis. Trans-thoracic echocardiography revealed an enlarged and hypokinetic right ventricle with
the McConnell sign, a small left ventricle, a
diastolic dyskinesia of the interventricular
septum, and a huge mobile worm-like
thrombus in both the atrial cavities, prolapsing into both ventricles. An immobile
fragment of the thrombus could also be
seen into the apex of the right ventricle
(▶ Figure 1, ▶ Figure 2 and Suppl. Video,
available online at www.thrombosis-online.
com). The Doppler- derived pulmonary artery systolic pressure (PAsP), according to
Bernoulli equation, was 52 mm Hg. A CT
scan was not considered mandatory since
the diagnosis of pulmonary embolism was
clear. The patient was treated with intravenous heparin and transferred to a cardiac
surgery department where an emergency
thrombectomy was planned on the basis of
the echocardiographic images. At cardiac
surgery, a 23-cm long thrombus, crossing
Correspondence to:
Franco Casazza, MD
Division of Cardiology
San Carlo Borromeo Hospital
Milan, Italy
E-mail: [email protected]
Received: December 23, 2014
Accepted after minor revision: February 13, 2015
Epub ahead of print: April 2, 2015
http://dx.doi.org/10.1160/TH14-12-1078
Thromb Haemost 2015; 114: 5–6
the interatrial septum through a patent foramen ovale (FO) was removed and the patent FO was sutured. Both the patient and
the fetus had an uncomplicated postoper-
ative course. At pre-discharge echocardiography, both right ventricle and PAsP were
normalised. The patient was discharged in
good clinical condition on low-molecular-
Figure 1: Apical
four-chamber view,
diastolic frame.
Huge, worm-like, right
heart thrombus extending into the left
atrium through the foramen ovale and prolapsing into both ventricles. A clot is also
visible in the apex of
the right ventricle.
Figure 2: Apical four
chamber view. RV=
right ventricle, LV= left
ventricle, RA= right atrium, LA= left atrium,
IAS=interatrial septum, TV= tricuspid
valve, MV= mitral
valve, TH= thromboembolus.
© Schattauer 2015
Thrombosis and Haemostasis 114.1/2015
Downloaded from www.thrombosis-online.com on 2017-06-17 | IP: 88.99.165.207
For personal or educational use only. No other uses without permission. All rights reserved.
6
T&H Images
References
Suppl. Video
Trans-thoracic echocardiography (apical fourchamber view) shows an enlarged and hypokinetic right ventricle, diastolic paradoxical
motion of the interventricular septum and a
huge, wormlike, right heart thrombus extending into the left atrium through interatrial
septum and prolapsing into both ventricles. A
clot is also visible in the apex of the right
ventricle.
The
Suppl. Video is available online at
www.thrombosis-online.com.
weight heparin. The delivery of the baby by
a caesarean section was uneventful. To our
knowledge, this is the first case of successfully surgical embolectomy in a pregnant
woman with acute pulmonary embolism
and four-chamber in transit heart thrombus.
▶
1. Acar G, Simsek Z, Avci A et al. Right heart freefloating thrombus in a pregnant woman with
massive pulmonary embolism: a case of “ emboli
in transit”. J Cardiovasc Med 2015; 16 (Suppl 13):
S51–54.
2. Myers PO, Bounameaux H, Panos A, et al. Impending paradoxical embolism: systematic review
of prognostic factors and treatment. Chest 2010;
137: 164–170.
3. Windecker S, Stortecky S, Meier B. Paradoxical
embolism. J Am Coll Cardiol 2014; 64: 403–415.
4. Fauveau E, Cohen A, Bonnet N, et al. Surgical or
medical treatment for thrombus straddling the
patent foramen ovale: impending paradoxical embolism? Report of four clinical cases and literature
review. Arch Cardiovasc Dis 2008; 101: 637–644.
Conflicts of interest
None declared.
Thrombosis and Haemostasis 114.1/2015
© Schattauer 2015
Downloaded from www.thrombosis-online.com on 2017-06-17 | IP: 88.99.165.207
For personal or educational use only. No other uses without permission. All rights reserved.