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Original Article

Clinical and echocardiographic diagnosis, follow upand management of right-sided cardiac thrombi

Bishav Mohan*, Shibba Takkar Chhabra, Amarpal Gulati,Chander Mohan Mittal, Gaurav Mohan, Rohit Tandon, S. Kumbkarni,Naved Aslam, Naresh K. Sood, Gurpreet Singh Wander

Department of Cardiology, Dayanand Medical College & Hospital, Unit Hero DMC Heart Institute, Ludhiana,

Punjab, India

a r t i c l e i n f o

Article history:

Received 1 February 2013

Accepted 10 August 2013

Keywords:

Right atrium

Thrombus

Thrombolysis

Oral anticoagulation

Echocardiography

Cardiac

Abbreviations: EICU, emergency intensiveenzyme linked immunosorbent assay; VQ,hypertension; CCP, chronic constrictive perthromboembolic pulmonary hypertension; HPASP, pulmonary artery systolic pressure; Smyocardial infarction; BMV, balloon mitralventricle outflow tract; CABG, coronary arte* Corresponding author.E-mail address: shibbachhabra@yahoo.co

0019-4832/$ e see front matter Copyright ªhttp://dx.doi.org/10.1016/j.ihj.2013.08.015

a b s t r a c t

Background: Right-sided cardiac masses are infrequent and have varied clinical presentation.

The present study describes the clinical features, echocardiographic findings andmanagement

of 19patientspresentingwith right-sidedcardiac thrombi ina tertiary care center innorth India.

Methods: This is a retrospective, single center observational study of consecutive patients

over the period January 2003e2008 admitted in our emergency intensive care unit (EICU).We

identified 38 patients with right-sided cardiac masses admitted to EICU diagnosed by

transthoracic echocardiography of which 19 patients had right-sided thrombus. The echo-

cardiographic findingswere reviewed by two cardiologists in all patients. Treatmentwas not

standardized and choice of therapy was based on judgment of attending physician.

Results: The mean age of patients with cardiac thrombus was 36.6 � 11.8 years. Right atrial

(n ¼ 17) and right ventricle (n ¼ 2) thrombi were associated with deep vein thrombosis

(DVT) in 7 (36.8%) and pulmonary embolism in 3 (15%) patients. 13 (68.4%) patients

appeared to have in situ mural thrombus. 12 patients were managed with oral anticoag-

ulants, 3 patients underwent surgery and 4 patients were thrombolysed. All the survivors

had a mean follow-up of 40 � 6 months (range e 18e50 months).

Conclusions: Prompt echocardiographic examination inanappropriate clinical setting facilitates

faster diagnosis andmanagement of patients with right-sided cardiac thrombi. High incidence

of in situmural thrombus and varied comorbidities predisposing to right-sided cardiac thrombi

besides DVT and pulmonary embolism need to be recognized. Oral anticoagulation and

thrombolysis appear to be themainstay of treatmentwith surgery limited for selected patients.

Copyright ª 2013, Cardiological Society of India. All rights reserved.

care unit; DVT, deep vventilation perfusion; PAicarditis; RA, right atrial;IV, human immunodeficTK, streptokinase; IV, invalvotomy; MVR, mitralry bypass grafting; ASD, a

m (B. Mohan).2013, Cardiological Societ

ein thrombosis; TEE, trans-esophageal echocardiography; ELISA,, pulmonary artery; RV, right ventricle; PAH, pulmonary arterialLA, left atrial; LV, left ventricle; CA, carcinoma; CTEPH, chroniciency virus; IVC, inferior vena cava; PFO, patent foramen ovale;travenous; rtPA, recombinant tissue plasminogen activator; MI,valve replacement; ATT, antitubercular treatment; RVOT, righttrial septal defect.

y of India. All rights reserved.

i n d i a n h e a r t j o u r n a l 6 5 ( 2 0 1 3 ) 5 2 9e5 3 5530

Right-sided cardiac masses are infrequent and do not have a

uniform clinical presentation. High index of suspicion and

prompt echocardiographic examination in an appropriate

clinical settingshall facilitate fasterdiagnosisandmanagement

of patientswith right-sided cardiac thrombi. The present study

describes the clinical features, echocardiographic findings and

management of 19 patients presentingwith right-sided cardiac

thrombi in a tertiary care center in north India.

1. Methods

This is a retrospective, single center study of all consecutive

patients admitted in our EICU from Jan 2003e2008. We identi-

fied 38 patients with right-sided cardiac masses admitted to

EICUdiagnosed by transthoracic echocardiography ofwhich 19

patients had right-sided thrombus. Masses such as vegetation,

primary or metastatic tumors and embryological remnants

were excluded.

Trans-thoracic echocardiography was done in all patients

using a Philips Envisor with a 2.5- or 3.5-MHz probe. Six patients

also underwent trans-esophageal echocardiography (TEE) using

a 5-MHzmonoplane echo probe. CardiacMRI was needed in one

patient to differentiate it frommyxoma. All patients underwent

vascular Doppler studies, D-dimer assay (by enzyme linked

immunosorbant assay [ELISA]) and three blood cultureswith the

first and last one at least half an hour apart. Ventilation perfu-

sion (VQ) scan was done in 10 patients where high pulmonary

artery (PA) pressures or dilation of right ventricle (RV) or exces-

sive mobility of themass pointed to the possibility of associated

pulmonary thromboembolism. The 9 patients who did not un-

dergo VQ scan included 4 patientswith rheumatic heart disease,

1 with RV cardiomyopathy, 2 patients with constrictive pericar-

ditis and 2 patients with sepsis where possibility of pulmonary

embolism was unlikely in presence of alternative diagnosis.

2. Results

Out of 38 patients identified with right-sided cardiac masses

19 had right-sided thrombus. The mean age of patients with

cardiac thrombus was 36.6 � 11.8 years (age range e 7 days to

64 years; median age e 33 years). There were 7 female and 12

male patients. Clinical and echocardiographic findings of pa-

tients are presented in flowcharts (Figs. 1 and 2).

All patients presented with dyspnea; 10, 6 and 3 patients

were in NYHA class II, III and IV, respectively at presentation.

One patient each presented with palpitations and easy fati-

gability. Pulmonary arterial hypertension (PAH) was present

in 17 patients at presentation. Ten patients (52.6%) presented

with mild PAH and 7 patients presented with moderate to

severe PAH. The severity of PAH was classified on the basis of

mean pulmonary artery pressure as mild (25e40 mmHg),

moderate (41e55 mmHg) or severe (>55 mmHg).1

In all, 36.8% (n ¼ 7) patients presented with deep venous

thrombosis (DVT); with ileo-femoral DVT (n ¼ 2), ileo-femoral

and popliteal (n ¼ 1) and popliteal vein (n ¼ 4) involvement.

One patient had a history of DVT 3 years ago which was not

present during the time of enrollment. This patient had

developed right atrial (RA) thrombi while he was on oral

anticoagulants. 15% (n ¼ 3) patients with right-sided thrombi

had evidence of pulmonary embolism.

Only 21% (n ¼ 4) patients had a history of prolonged

immobilization and three of these had associated DVT.

Similar number of patients (n ¼ 4) had associated tuberculosis

[pleural effusion 1, pott’s spine 1, tubercular chronic

constrictive pericarditis (CCP) 2], and half of these had asso-

ciated large vein occult DVT.

Two patients presented with sepsis and infected RA

thrombus. One of these patients was a 7 days female, pre-

sentingwithcerebrovascular accident followingumbilical vein

cannulationandotherpatientpresentedwithpyopericardium,

pyomyositis and history of acute febrile illness. Four patients

hadassociated rheumaticheartdiseaseall ofwhomhadsevere

mitral stenosis with associated RV dysfunction (n ¼ 1), left

ventricle (LV) dysfunction (n¼ 1) left atrial (LA) thrombus (n¼ 1)

and organic tricuspid valve disease (n ¼ 1). Associated malig-

nancy (carcinoma (CA) breast post-irradiation and surgery),

connective tissue disease (Scleroderma with chronic throm-

boembolic pulmonary hypertension (CTEPH) with RV

thrombus), RV cardiomyopathy and human immunodefi-

ciency virus (HIV) positive status on follow-upwas detected in

one patient each. Three patients had associated RV dysfunc-

tion and 2 patients had LV systolic dysfunction.

2.1. Imaging characteristics

The echocardiographic findings were recorded and reviewed

by two cardiologists in all patients. The right-sided thrombi

varied in size from 1.1 � 0.9 to 6 � 8.5 cm. Most of these were

regular (84%) with varying shapes {spherical (26%), oval/ovoid

(36%), vermicular (21%), rhomboid and spindle shaped}.

Broad-based pedicle could be identified in one of the cases,

rest were non-pedunculated. Barring 3 cases, the attachment

of thrombi could be localized from inferior vena cava (IVC)

opening (3/19), RA roof (3/19), Eustachian valve (2/19), inter

atrial septum (4/19), RV apex (2/19) and from body of RA and

RA appendage (2/19). Mobility was preserved in 6 of these with

2 thrombi extending across tricuspid valve and 1 across

tricuspid valve upto RV outflow tract. In 3 patients with patent

foramen ovale (PFO) the thrombi extended across tricuspid

valve and mitral valve; tricuspid, mitral and aortic valve; and

across mitral and aortic valve, respectively. Two patients (one

with scleroderma, CTEPH and other with RV myocardial

infarction and RV dysfunction) had right ventricle thrombi.

Mild and moderate to severe PAH was found in 52.6% (n ¼ 10)

and 36.8% (n ¼ 7) patients, respectively.

3. Management and follow-up

Treatment was not standardized and choice of therapy was

based on judgement of attending physician. Twelve patients

were managed with oral anticoagulants, 3 patients underwent

surgery and 4 patients were thrombolysed. The dose of

thrombolytic agents used was e Streptokinase (STK) e intra-

venous (IV) bolus 250,000 units over 30min followedby infusion

of 100,000 units/h for 12e24 h and Recombinant tissue plas-

minogen activator (rtPA)e IV bolus of 15mg in 10min followed

Fig. 1

i n d i a n h e a r t j o u rn a l 6 5 ( 2 0 1 3 ) 5 2 9e5 3 5 531

by 85 mg in next 2 h (total ¼ 100 mg). All the survivors had a

mean follow-up of 40 � 6 months (range e 18e50 months).

Echocardiography, clinical examination and hypercoagu-

lability profile was obtained at 6 monthly visits. All the pa-

tients were kept on oral anticoagulants in long term with INR

maintained within 2.0e3.0.

Of the 17 survivors 15 patients had no right-sided thrombi

on echocardiography follow up at 6 months. Two patients had

persistence of thrombus; one of these had a history of DVT

3 years prior to presentation. The second patient had Inferior

wall and RV myocardial infarction (MI) with RV thrombi per-

sisting for first 6 months but thereafter completely dis-

appearing at 3rd visit (9months). Fungal and bacterial etiology,

respectively, was found in the two patients presenting with

infected RA thrombus (Fig. 3) and each of them responded to

heparin infusion along with prolonged parenteral antibiotics/

antifungals. Amongst the four patients presenting with severe

mitral stenosis (MS) (Fig. 4), two patients underwent balloon

mitral valvotomy (BMV) and mitral valve replacement (MVR)

successfully after 6 weeks of disappearance of RA thrombus.

The other two patients with severe MS were kept on medical

management. Both patients with chronic constrictive peri-

carditis (tubercular etiology) underwent surgery, received 9

months antitubercular treatment (ATT) and remained on oral

anticoagulation for one year (Fig. 5).

Three patientswith extension of thrombus into the left side

of heart (Fig. 6) were either thrombolysed (2 cases with

streptokinase) or sent for surgery (1 case). Onepatientwhowas

thrombolysed and the other patient who underwent surgery

expired immediately after thrombolysis and intraoperatively,

respectively. One survival in the medical group was free of

thrombi at 6months of followup. His thrombophilia profile for

inherited hyper coagulant states was negative though he was

continued on lifelong anticoagulation. Two patients with

thrombi extending across the TV up to the RV outflow tract

(RVOT) had associated pulmonary embolism and were suc-

cessfully thrombolysed.

4. Discussion

Right heart thrombi can be classified into two groups. The first

group represents embolized deep venous thrombi that are

temporarily lodged in the right atrium or ventricle and are

often referred to as “emboli in transit” or thromboembolism

and the second group represents thrombi in situ or the mural

thrombi which are immobile. They present a distinctive

appearance on two-dimensional transthoracic and trans-

esophageal echocardiography. Since the initial case report by

Covarrubias2 and colleagues, many authors3e6 have described

thrombus in transit as highly mobile, coiled, or serpiginous

masses moving within the right atrium or ventricle. These

often prolapse into the tricuspid or pulmonic valve during the

cardiac cycle. A point of attachment often is unseen or is

Fig. 2 e Flow chart depicting imaging characteristics of right-sided masses and the treatment strategy.

i n d i a n h e a r t j o u r n a l 6 5 ( 2 0 1 3 ) 5 2 9e5 3 5532

visualized as a thin stalk. Thromboemboli are difficult to

distinguish frommyxomas, and acoustic difference allows the

discrimination.5

Mural thrombi, show less motion during the cardiac cycle,

a broad-based attachment to the heart wall, and occasional

focal calcification. Mural RA thrombi are seen in conditions

Fig. 3 e TTE image (sub costal view) showing round well

circumscribed heterogenous mass attached to inter atrial

septum in a seven day old new born.

like cardiomyopathies, post coronary artery bypass grafting

(CABG), post atrial septal defect (ASD) repair, patients with

permanent pacemaker leads or hyper alimentation catheters

or ventriculoatrial shunts in situ.7 Such patients usually have

enlarged RA or decreased cardiac output with relative stasis of

blood or have evidence of endocardial damage to RA after

Fig. 4 e TEE (bicaval view) showing oval homogenous mass

with translucency at periphery. Mass was immobile below

RA appendage in a patient of severe mitral stenosis, PAH

with severe RV systolic dysfunction.

Fig. 5 e TEE (bicaval view) showing irregular mobile sea

anemone like mass in protruding in right atrium in a

patient of constrictive pericarditis.

i n d i a n h e a r t j o u rn a l 6 5 ( 2 0 1 3 ) 5 2 9e5 3 5 533

surgery. In this series only one patient had PPI leads in situ

and three had associated RV dysfunction.

The present study signifies the importance of high inci-

dence of in situ thrombus rather than thrombus in transit. The

incidence of mural thrombi is believed to be more in this se-

ries owing to characteristics of thrombi; n¼ 13 (68.4%) thrombi

were immobile with localized attachments as depicted in flow

chart. Moreover, underlying enlarged RA and decreased car-

diac output with relative stasis of blood predisposed to for-

mation of mural RA thrombi as in patients with severe mitral

stenosis and associated organic tricuspid valve disease, RV

dysfunction and LV dysfunction; constrictive pericarditis,

RV cardiomyopathy, Inferior and RV myocardial infarction

with RV dysfunction.

Most of the RA thrombi in this series were regular homog-

enous or multi lobed structures with or without central echo-

lucency. Theywere without a pedicle but appeared attached to

a particular point in right atrium or to one of the inlets in right

Fig. 6 e TEE image (four chamber view) showing vermicular

mass moving across mitral value via PFO in a patient of

tubercular pneumonia and DVT.

atrium. None of them was attached to the tricuspid leaflet,

though if mobile across the tricuspid valve they appeared to

move along the tricuspid leaflets into the RV in diastole unlike

vegetation on tricuspid leaflet. Unlike LV thrombus, none had a

layered appearance, except the RV thrombus. The infected

thrombus had a more heterogenous and mottled appearance,

were immobile without any extension, had a short clinical

history without significant immobilization and were not

associated with pulmonary embolization or any signs of

persistent bacteremia. The RV thrombi were immobile ho-

mogenous regular structures attached to the RV apex, taking

its shape and associated with RV dysfunction.

15% (n ¼ 3) patients were diagnosed to have pulmonary em-

bolism. Echocardiographic studies in patients with pulmonary

embolism show an incidence of right heart thromboembolism

between 3% and 23%, with a combined incidence of 9% across

several large series studying consecutive patients.8e12 On the

other hand, pulmonary thromboembolism may be seen up to

98%ofcasesof rightatrial thromboembolism.13177casesof right

heart thromboembolismwere analyzed ina retrospectivemeta-

analysis by Peter et al13 with pulmonary thromboembolism

present in98%of cases. The treatmentsadministeredwerenone

(9%),anticoagulation therapy(35.0%), surgicalprocedure (35.6%),

or thrombolytic therapy (19.8%). The overall mortality rate was

27.1%. The mortality rate associated with no therapy, anti-

coagulation therapy, surgical embolectomy, and thrombolysis

was 100.0%, 28.6%, 23.8%, and 11.3%, respectively. Using multi-

variate modeling, thrombolytic therapy was associated with an

improved survival rate (p < 0.05) when compared either to

anticoagulation therapy or surgery.

In the present study, right heart thrombi were associated

with mortality of 10.5% over 18-month follow up. Treatment

administeredwasonly anticoagulants in 12 (63%), thrombolysis

in 4 (21%), and surgery in 3 (15.7%) cases. Oral anticoagulation

remains to be the gold standard formural thrombus given their

success rate of 91.6% in dissolving such masses. Thrombolysis

should be given for compelling indications like right atrial

thromboembolism, pulmonary thromboembolism, increased

fragility andmobility of thesemasses, and extensionof thrombi

into left side across PFO. Surgery is indicated for indications

other than just mere presence of right-sided thrombus, for

instance, chronic constrictive pericarditis. Valve surgery and

simultaneous removal of RA clot is also recommended though

in the present series it was done only after resolution of clot.

The RA thrombi-behaves same as platelet rich red thrombi

disappearing slowly with oral anticoagulants or more early

with thrombolysis. Infected thrombus is a form intermittent

between a thrombus and vegetation caused by local seeding of

a thrombus by the highly virulent infected material during

transient bacteremia in appropriate clinical conditions. In the

present series, two patients had infected thrombi one with

pyomyositis and other with septicemia and a history of um-

bilical vein cannulation. One of these cases had an undulating

membrane over the RA thrombi. Thrombus is generally hypo

vascular tissue, so ingress of antibiotics and immune system

antibodies via vasculature is thought to be poor and prompt

surgical resection of the infected thrombus should be per-

formed, followed by prolonged administration of antibiotics.

However both our patients responded to antibiotics along

with oral anticoagulants.

i n d i a n h e a r t j o u r n a l 6 5 ( 2 0 1 3 ) 5 2 9e5 3 5534

Tuberculosis a widely prevalent infectious disease in In-

dian subcontinent and was seen in 21% cases. Half of these

cases also had associated DVT. Deep vein thrombosis was

occult in more than 50% of cases. Tuberculosis as a risk factor

for venous thrombosis has been mentioned in various stud-

ies.14e22 Deep vein thrombosis occurred in 50% of patients in a

series of 380 patients of tuberculosis along with various he-

matological abnormalities.23 The hypercoagulable state in

tuberculosis is caused by increased anti-phospholipid anti-

bodies, decreased protein C and protein S, decreased anti-

thrombin III, thrombocytosis, increased fibrinogen levels,

increased fibrinogen degradation products and t-PA causing

impaired fibrinolysis.15e17,20 Mechanical factors like lymph-

adenopathy causing venous obstruction and subsequent

thrombosis has also been reported, as is antitubercular drug

rifampicin causing hypercoagulable state.21,22

Patients having RA mass extending into the left side had

the worst prognosis of all. Two out of three patients in this

series expired with one immediately after thrombolysis while

the second one expired intraoperatively.

The most effective therapy for patients with right heart

thrombi remains unknown. This issue is critical because the

presence of a right heart thromboembolus complicating a

pulmonary thromboembolism appears to carry a poor prog-

nosis.3,5,6,24,25 Chartier et al8 reported amortality rate of 45% in

the most recent series of 38 consecutive patients with right

heart thromboembolism. All of these deaths occurred within

the first 24 h of hospitalization, signifying the need to rapidly

diagnose and treat right heart thromboembolism.8

Existing published reports differ in their recommendations

for treatment by advocating surgical removal,4,9 administra-

tion of thrombolytic agents8 or anticoagulation therapy24 with

heparin. The last analysis of patients with right heart

thromboembolism (n ¼ 119) found similar mortality rates for

surgery, thrombolysis, and heparin anticoagulation therapy

(38%, 38%, and 30%, respectively) and thus concluded that

heparin therapy was the treatment of choice.24

Unfortunately, there are no prospective trials to defini-

tively answer this question or to assess other risk factors that

may be related to mortality. Our results suggest that throm-

bolytic therapy was associated with a reduction in mortality

for thromboembolus while oral anticoagulation was enough

for mural thrombus. Oral anticoagulants alone for free

floating thrombus may be hazardous with the possibility of

thrombus embolizing to pulmonary circulation.

Surgical embolectomy has its own set of potential com-

plications including an inherent delay of at least hours, gen-

eral anesthesia, cardiopulmonary bypass, and the inability to

remove coexisting pulmonary thromboemboli beyond the

central pulmonary arteries. One of the major advantages of

the surgical approach is the ability to simultaneously repair a

PFO, thus reducing the risk of a subsequent paradoxical em-

bolism. The percutaneous catheter directed retrieval of clots is

a promising possibility, but only few cases have been reported

to date.26,27 In contrast, thrombolytic therapy can be admin-

istered quickly and results in the simultaneous thrombolysis

of cardiac and pulmonary arterial thromboemboli as well as a

thrombus in the femoral venous circulation. The major

complication of thrombolytic therapy is significant bleeding,

which occurs in as many as 22% of patients.28

5. Limitations

Thisstudyis relativelysmall sizedretrospectivestudywithwide

variability inclinicalaspectsof thestudiedpatients.However, in

absence of any previous published reports on the entity in this

region, our findingsmight be an impetus for future work in this

field. PE was diagnosed in 3 (15%) patients in the present study.

However, VQ scan employed for the diagnosis is not a sensitive

modality to detect small thrombi and hence there might be an

under estimation of the prevalence of PE. Also, of the 19 studied

patients, 9 patients did not undergo VQ scan as there were

alternative explanations available for PAHand/or RVdilatation.

These patients could still havehad PE. As regardsmanagement,

the treatment with thrombolysis and anticoagulation resulted

in good outcome in these patients with right heart thrombi,

most of which appeared to be mural thrombi. However, in the

small patient population comparison amongst the treatment

modalities was not possible. In our experience, thrombolysis

appears to be a bettermodality in patientswith severe PAH and

right-sided thrombi.

6. Conclusion

Prompt echocardiographic examination in an appropriate clin-

ical setting facilitates faster diagnosis and management of pa-

tientswith right-sidedcardiac thrombi.High incidenceof in situ

mural thrombusandvariedcomorbiditiespredisposing to right-

sided cardiac thrombi besides DVT and pulmonary embolism

need to be recognized. Oral anticoagulation and thrombolysis

are themainstay of treatment with surgery limited for selected

patients. Oral anticoagulation for all and thrombolysis for high

risk thrombi associatedwithmobile fragile thrombusorwith PE

is recommended. However, in transit thrombus presenting

across PFO is themost difficult groupwith uncertain prognosis.

Conflicts of interest

All authors have none to declare.

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