Management of mobile right heart thrombi: a prospective series
Section snippets
Patient selection
We performed a transthoracic echocardiogram from November 1997 to June 1999 in all consecutive patients admitted to the intensive care unit for suspected acute massive PE. The diagnosis was confirmed by perfusion lung scan or pulmonary angiography. Transthoracic echocardiogram was obtained as the first imaging technique within 70±20 min after the onset of symptoms. And the immobile thrombi developed in situ were not included in this study.
Echocardiographic imaging
All patients underwent transthoracic echocardiography as
Clinical data
Of the 335 patients admitted for acute PE, we identified 12 patients with echocardiographic evidence of MRHT. All presented with dyspnea and polypnea. Tachycardia was present in all but one patient who was treated by a β-blocker. All patients had presented, before admission, syncope during exertion. Chest pain was reported by five patients. Clinical signs of right heart failure were present in five cases. All patients had an abnormal ECG. The other clinical characteristics are presented in
Echocardiography
MRHT can be observed [8] by echocardiography [9] in 4–18% of patients of severe PE [10]. Before the development of echocardiography, MRHT were identified at autopsy. Thirty-six cases were reported by Boulay et al. [11] in a series of 2000 consecutive autopsies. Franzoni et al. [12] were able to detect a MRHT in 5 of 30 consecutive unselected patients with acute PE. In that study, thromboemboli were detected in 4 of 7 patients who underwent echocardiography within 20 h from the onset of
Study limitations
The first limitation of this study is its size. Second, no Doppler ultrasound has been performed with these patients between 7 days and 1 year. Thus, the functional parameters such as the estimate of systolic pulmonary artery pressure within 3 weeks remain unknown. However, MRHT is a rare condition; our study is the first prospective study single-center with a follow-up of 1 year; indeed the largest single-center reported is a retrospective study with 38 patients [1]. On the other hand, a
Conclusions
Echocardiography must be performed systematically as soon as PE is suspected. It is rapid, practical and sensitive technique for the fast identification of MRHT in patients with PE. The clinical suspicion of PE associated with an image of MRHT is sufficient to initiate early treatment of high-risk patients without further investigation. All seven patients treated with rt-PA had a good outcome and showed a clear and rapid improvement of echocardiographic and scintigraphic data. These encouraging
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