ISPUB.com / IJTCVS/9/1/8409
  • Author/Editor Login
  • Registration
  • Facebook
  • Google Plus

ISPUB.com

Internet
Scientific
Publications

  • Home
  • Journals
  • Latest Articles
  • Disclaimers
  • Article Submissions
  • Contact
  • Help
  • The Internet Journal of Thoracic and Cardiovascular Surgery
  • Volume 9
  • Number 1

Original Article

Right Heart Free-Floating Thrombus In A Patient With History Of Breast Cancer

N Barbetakis, A Efstathiou, G Samanidis, C Lafaras, D Platogiannis, T Bischiniotis, I Fessatidis

Keywords

breast cancer, right heart, thrombus

Citation

N Barbetakis, A Efstathiou, G Samanidis, C Lafaras, D Platogiannis, T Bischiniotis, I Fessatidis. Right Heart Free-Floating Thrombus In A Patient With History Of Breast Cancer. The Internet Journal of Thoracic and Cardiovascular Surgery. 2006 Volume 9 Number 1.

Abstract

Free-floating right heart thrombi are a rare phenomenon, generally diagnosed when echocardiography is performed in patients with suspected or proven pulmonary embolism and have a dismal prognosis.
A case of a 67-year-old female with a history of breast cancer and a free floating thrombus in the right atrium is presented. She was admitted with symptoms and signs of acute right heart failure. Further investigation revealed a large free serpentine right atrial thrombus, which sometimes prolapsed through the tricuspid valve into the right ventricle. The patient underwent surgical embolectomy with exploration of the right chambers and pulmonary arteries under full cardiopulmonary by pass. There were no perioperative complications. Screening tests for hypercoagulability were normal except for positive antiphospholipid antibodies. Eighteen months later the patient is free of symptoms and with no recurrence of malignant disease.

Right heart thrombi are a severe form of venous thromboembolic disease and justify diagnosis and treatment in emergency. In our case, surgery was the treatment of choice although thrombolysis could be advocated first. Breast cancer is probably a predisposing factor for hypercoagulability.

 

Background

Floating right heart thrombi are uncommon but their true prevalence is unknown [1]. In most cases, they are transit from the legs to pulmonary arteries and thus are a form of venous thromboembolic disease [2]. They can embolize at any moment and emergency treatment is required especially in view of their documented dismal prognosis [3].

Malignant disease is an independent predisposing factor for hypercoagulability. Breast cancer and use of tamoxifen have already been suspected for hpercoagulability abnormalities and thrombi formation [4].

A case of a 67-year-old female with a history of breast cancer and a free-floating thrombus in the right atrium is presented.

Case presentation

A 67-year-old woman presented to our department with dyspnea, chest pain and occasional dizzy spells. Her past medical history revealed that she underwent modified radical mastectomy for breast cancer 5 years ago. Postoperatively she treated with adjuvant chemoradiotherapy and tamoxifen. Clinical examination revealed cyanosis, hepatomegaly and pretibial oedema. Laboratory data was normal except for leukocytosis (14000/mm3) and elevated erythrocyte sedimentation rate (62mm/1h). Electrocardiogram showed sinus tachycardia and right bundle branch block. Chest x-ray revealed cardiomegaly. Transthoracic echocardiography showed a large mobile thrombus within the right atrium which sometimes prolapsed through the tricuspid valve into the right ventricle (Figure 1).

Figure 1
Figure 1: A large mobile thrombus within the right atrium which sometimes prolapsed through the tricuspid valve into the right ventricle.

No thrombosis was detected at venous doppler ultrasound examination. Abdominal ultrasound showed prominent inferior vena cava and dilated hepatic veins with minimal ascites. Additional investigation (thorax an abdominal computed tomography) was normal.

Because of the risk of pulmonary thromboembolism and acute obstruction of the tricuspid valve, emergency surgery was performed. The patient underwent surgical embolectomy with exploration of the right chambers and pulmonary arteries under full cardiopulmonary by pass. A lage free serpentine right atrial thrombus was removed (Figure 2).

Figure 2
Figure 2: A large free serpentine right atrial thrombus was removed.

The patient had an uneventful recovery. Her postoperative transthoracic echocardiogram showed good right ventricular contractility with no residual thrombus in the right atrium.

Screening tests for hypercoagulability included normal levels of serum fibrinogen , d-dimers, protein C and S, antithrombin III but positive antiphospholipid antibodies.

After a period of subcutaneous low molecular weight heparin, the patient was discharged on oral anticoagulation (acenocoumarol), adjusted to maintain an international normalized ratio (INR) between 2 and 3 times control. Eighteen months later, the patient is free of symptoms and with no recurrence of malignant disease.

Discussion

Free floating right heart thrombi are a rare phenomenon, generally diagnosed when echocardiography is performed in patients with suspected or proven pulmonary embolism and have a dismal prognosis. Severe pulmonary embolism usually coexists with floating right heart thrombi [5].

Sometimes the differential diagnosis of a floating right heart thrombus may be difficult. Congenital structures such as Chiari network, persistent eustachian or thebesian valves, atrial septal aneurysms or acquired conditions such as intracardiac tumors, devices and vegetations need to be considered [6,7,8]. Any doubt should lead to the performance of transesophageal echocardiogram which is rapid, semi-invasive bedside investigation. According to most authors, diagnosis of floating right heart thrombus by echography allows immediate treatment and additional investigations (lung scintigraphy, computed tomography scan, pulmonary angiography) may be performed after treatment [1,3]. Floating right heart thrombi are an extreme therapeutic emergency and any delay to treatment could be lethal [9,10]. Twenty one percent of the patients die within the first day of admission [9].

The role of surgery for severe pulmonary embolism with or without concomitant floating right heart thrombus has been widely discussed [11]. Thrombolysis may be advocated first [12,13]. Thrombolysis has the advantage of acting in the intracavitary thrombus, on the pulmonary pole and at least partially on deep vein thrombosis which is usually seen in association [14]. The potential risks are the migration of fragments following clot lysis in patients with an unstable hemodynamic ondition or a recurrence of embolism following partial dissolution of the venous thrombus [10].

In our case, due to the risk of pulmonary thromboembolism and acute obstruction of the tricuspid valve, emergency surgery was performed altough thrombolysis could be the first line treatment. In fact only a prospective multicenter rndomized trial will be enable to determine the real incidence of mobile heart thrombus in acute pulmonary embolism and the codification the respective indication for medical or surgical treatment.

References

1. Goldhaber SZ: Optimal strategy for diagnosis and treatment of pulmonary embolism due to right atrial thrombus. Mayo Clin Proc 1988;63:1261-64.
2. Panidis IP, Kotler MN, Mintz GS, Ross J: Clinical and echocardiographic features of right atrial masses. Am Heart J 1984;107:745-758.
3. Chapoutot L, Nazeyrollas P, Metz D: Floating right heart thrombi and pulmonary embolism: diagnosis, outcome and therapeutic management. Cardiology 1996;87:169-174.
4. Fisher B, Constantino JP, Wickerham DL: Tamoxifen for prevention of breast cancer: Report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst 1998;90:1371-1388.
5. Casazza F, Bongarzoni A, Centonze F, Morpurgo M : Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism. Am J Cardiol 1997;79:1433-1435.
6. Felner JM, Churchwell AL, Murphy DA: Right atrial thromboemboli: clinical, echocardiographic and pathophysiologic manifestations. J Am Coll Cardiol 1984;5:1041-1051.
7. Yarnal JR, Smiley WH: Right atrial mass simulated echocardiographically by a Swan-Ganz catheter. Chest 1978;74:478-479.
8. Covarrubias EA, Sheikh MU, Fox LM: Echocardiography and pulmonary embolism. Ann Intern Med 1977;87:720-721.
9. European Working Group on Echocardiography. The European Cooperaive Study on the clinical significance of right heart thrombi. Eur Heart J 1989;10:1046-1059.
10. Farfel Z, Shechter M, Vered Z, Rath S, Goor D, Gafni J: Review of echocardiographically diagnosed right heart entrapment of pulmonary emboli-in-transit with emphasis on management. Am Heart J 1987;113:171-178.
11. Gray HH, Morgan JM, Paneth M, Miller GAH: Pulmonary embolectomy for acute massive pulmonary embolism: an analysis of 71 cases. Br Heart J 1988:60:196-200.
12. Cuccia C, Campana M, Franzoni P, Faggiano P, Volterani M, Musmeci G, Visioli O: Effectiveness of intravenous rt-PA in the treatment of massive pulmonary embolism and right heart thromboembolism. Am Heart J 1993;126:468-472.
13. Goldhaber SZ, Nagel JS, Theard M, Levine JD, St John Sutton MG: Treatment of right atrial thrombus with urokinase. Am Heart J 1988;115:894-897.
14. Goldhaber SZ: Thrombolysis for pulmonary embolism. Prog Cardiovasc Dis 1991;34:113-134.

Author Information

Nikolaos Barbetakis, MD, PhD
Cardiothoracic Surgeon, Department of Cardiothoracic Surgery, Theagenio Hospital

Andreas Efstathiou, MD, PhD
Cardiothoracic Surgeon, Department of Cardiothoracic Surgery, Geniki Kliniki

Georgios Samanidis, MD
Resident in Cardiothoracic Surgery, Department of Cardiothoracic Surgery, Theagenio Hospital

Christos Lafaras, MD, PhD
Cardiologist, Department of Cardiology, Theagenio Hospital

Dimitrios Platogiannis, MD, PhD
Cardiologist, Department of Cardiology, Theagenio Hospital

Theodoros Bischiniotis, MD, PhD
Chief Cardiologist, Department of Cardiology, Theagenio Hospital

Ioannis Fessatidis, MD, PhD
Department of Cardiothoracic Surgery, Geniki Kliniki

Your free access to ISPUB is funded by the following advertisements:

Advertisement

 

BACK TO TOP
  • Facebook
  • Google Plus

© 2013 Internet Scientific Publications, LLC. All rights reserved.    UBM Medica Network Privacy Policy

Close

Enter the site

Login

Password

Remember me

Forgot password?

Login

SIGN IN AS A USER

Use your account on the social network Facebook, to create a profile on BusinessPress