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Management of large right heart thrombi and vegetations is challenging. Medical management may be insufficient to prevent embolization or treat infection. Surgery carries a high mortality and is often not an option for these patients with multiple comorbidities. We present a case series of four patients describing percutaneous aspiration thrombectomy with AngioVac device as a safe and effective treatment for high-risk patients with right heart thrombi or tricuspid valvular vegetations. Indexing words 1. Right atrial mass 2. Tricuspid valve vegetation 3. Aspiration thrombectomy • Management of large right heart thrombi and vegetations is challenging. • Surgery carries a high mortality and is often not an option for these patients with multiple comorbidities. • Our case series shows AngioVac device as a safe and effective treatment for high-risk patients with right heart thrombi or vegetations. [ABSTRACT FROM AUTHOR]

Acute pulmonary embolism (PE) is a relatively common vascular disease with potentially life-threatening complications. Right heart thrombi deteriorate the prognosis. Due to the known high lethality, such a clinical situation requires immediate diagnosis and treatment. With the existing different management options for intracardiac blood clots, the optimal one is still uncertain. The article describes the experience of therapeutic and diagnostic tactics in a patient with PE and thrombosis of two right chambers of the heart with a favorable outcome while the conservative approach was used.

Free-floating right-heart thrombus (FFRHT) in the context of a pulmonary embolism (PE) is a rare but serious encounter with no guidelines addressing its management. We performed a systematic review and meta-analysis addressing prevalence, clinical behavior, and outcomes of FFRHT associated with PE. Among the included 397 patients with FFRHT and PE, dyspnea was the main presenting symptom (73.3%). Obstructive shock was documented in 48.9% of cases. Treatment with thrombolytic therapy, surgical thrombectomy, and percutaneous thrombectomy was documented in 43.8%, 32.7%, and 6.5% of patients, respectively. The overall mortality rate was 20.4%. Syncope (p : 0.027), chest pain (p : 0.006), and obstructive shock (p : 0.037) were significantly associated with mortality. Use of thrombolytic therapy was significantly associated with survival (p : 0.008). A multivariate logistic regression model to determine mortality predictors revealed that syncope (OR: 1.97, 95% CI: 1.06–3.65, p : 0.03), and obstructive shock (OR: 2.23, 95% CI: 1.20–4.14, p : 0.01) were associated with increased death odds. Treatment with thrombolytic therapy (OR: 0.22, 95% CI: 0.086–0.57, p : 0.002) or surgical thrombectomy (OR: 0.35, 95% CI: 0.137–0.9, p : 0.03) were associated with reduced death odds. Meta-analysis of observational studies revealed a pooled prevalence of FFRHT among all PE cases of 8.1%, and overall mortality of 23%. Although uncommon, the presence of FFRHT in the context of PE is associated with high obstructive shock and mortality rates. Favorable survival odds are observed with thrombolytic therapy and surgical thrombectomy. Data are derived from case reports and observational studies. Clinical trials elucidating these findings are needed. [ABSTRACT FROM AUTHOR]

Rationale: Right heart thrombi (RiHT) is characterized by the presence of thrombus within the right atrium or right ventricle (RV). Current literature suggests pulmonary embolism (PE) with RiHT carries a high mortality. Guidelines lack recommendations in managing RiHT. We created a pooled analysis on RiHT and report on our institutional experience in managing RiHT. We aimed to evaluate whether patient characteristics and differing treatment modalities predict mortality. Methods: We created a pooled analysis of case reports and series of patients with RiHT and PE between January 1956 and 2017. We also reviewed a series of consecutive patients with RiHT identified from our institutional PE registry. Age, shock, RV dysfunction, clot mobility, treatment modality, and hospital outcome had to be reported. Results: We identified 316 patients in our pooled analysis. Patients received the following therapies: no treatment 15 (5%), systemic anticoagulation 73 (23%), systemic thrombolysis 108 (34%), surgical embolectomy 101 (32%), catheter-directed therapy 11 (3%), and systemic thrombolysis with surgery 8 (3%). In-hospital mortality was 18.7%. Univariate analysis showed age and shock reduced odds of survival. Multivariate analysis showed shock reduced odds of survival (odds ratios [OR] 0.36, 95% confidence interval [CI]: 0.19-0.72, P ≤ .01) while age, RV dysfunction, and clot-mobility did not affect mortality. In a reduced multivariate analysis adjusting for shock, treatment modality, and clot location alone, systemic thrombolysis increased odds of survival when compared to systemic anticoagulation (OR 2.72, 95% CI: 1.11-6.64, P = .02). Our institutional series identified 18 patients, where in-hospital mortality was 22.2%, 18 (100%) had RV dysfunction, and 5 (28%) had shock. Patients received the following therapies: systemic anticoagulation 8 (44.4%), systemic thrombolysis 4 (22.2%), surgical embolectomy 4 (22.2%), and catheter-directed thrombolysis 2 (11.1%). Conclusion: Presence of shock in RiHT is an independent predictor of mortality. Systemic thrombolysis may offer increased odds of survival when compared to systemic anticoagulation. Our findings should be interpreted with caution as they derive from retrospective reports and subject to publication bias. [ABSTRACT FROM AUTHOR]

Résumé Objectif Décrire la prise en charge et l'évolution des embolies pulmonaires à haut risque de décès associées à des thrombi intracavitaires droites. Matériel et méthodes Il s'est agi d'une cohorte prospective qui s'est déroulée sur 54 mois du 1er mars 2012 au 30 septembre 2015. Ont été inclus les patients chez qui une embolie pulmonaire à risque de décès haut et intermédiaire-haut a été diagnostiquée. Les patients ont été subdivisés en deux groupes selon que l'échographie cardiaque retrouvait ou non un thrombus intracavitaire droite (TIC+ vs TIC−). Le suivi a duré 30 jours. Nous avons supposé que les données suivaient une loi normale et le test de Khi2 a été utilisé avec un seuil de significatif fixé à p < 0,05. Les courbes de survie ont été obtenu grâce au logiciel STATA. Résultats La prévalence des embolies associées à des thrombi intracavitaires était de 4 %. Le groupe TIC+ était caractérisé par une proportion significativement plus élevée dans le groupe TIC−. Dans le groupe TIC+, la thrombolyse réduisait significativement la mortalité donnant une survie à 30 jours de 80 % contre 20 % chez les patients qui recevaient uniquement de l'héparine. Conclusion Les embolies pulmonaires associées à des thrombi du cœur droit notamment de l'oreillette ne sont pas exceptionnelles. Ces patients courent un grand risque de décès précoce. La thrombolyse améliore la survie. Abstract Objective To describe the management and evolution of high risk of death pulmonary embolism associated with right heart thrombi. Material and methods We conducted a prospective cohort survey over a 54 month-period, from March 1st, 2012 to September 30th 2015. Were included all patients with pulmonary embolism and having high or intermediate-high risk of death. Patients were divided into two groups according to whether cardiac Doppler-echography found a thrombus in the right chambers or not (ICT+ vs. ICT−). The survival curves for the patients were obtained using the software STATA. Results The prevalence of pulmonary embolism associated with right heart thrombi was 4% in our study. Thrombi were mobile, straight localization in all cases. The ICT + group was characterized by a significantly higher proportion of congestive heart and chronic lung disease. The proportion of patients' thrombolysis was significantly higher in the ICT-group. In the ICT + group, thrombolysis significantly reduced mortality giving a 30-day survival of 80% against 20% among patients receiving only heparin. Conclusion Pulmonary embolism associated with right heart thrombi including the atrium are not exceptional. These patients are at high risk of early death. Thrombolysis is significantly improving the mortality of pulmonary embolism associated with right-sided heart thrombi. [ABSTRACT FROM AUTHOR]

Introduction: The occurrence of right heart thrombus (RiHT) in pulmonary embolism (PE) carries poor prognosis. Type A Thrombi are serpiginous, highly mobile with high mortality. Type B Thrombi are less mobile and have better prognosis. Type C is intermediate in all characteristics. Methods: This is an observational study done in patients presenting with RiHT with PE to the emergency unit of our institute from March to August 2016. A total of seven patient's clinical and electrocardiographic data were collected with a history of deep vein thrombosis or hypercoagulability. Results: This case series of seven patients with right heart thrombi in pulmonary embolism showed a predominance of male patients, with right ventricle dysfunction and pulmonary hypertension in all cases. Conclusion: Early fibrinolysis in type A thrombus had a favourable outcome. Mortality was 29% in our series.

In patients with pulmonary thromboembolism, right heart thrombi are uncommon or underdiagnosed. They may form in situ or arise due to migration from the peripheral venous system. Their presence in pulmonary embolism indicates a grave prognosis and complicates treatment decisions. We report a case of mobile right ventricular thrombus with massive pulmonary thromboembolism who had a rapid fatal course despite early treatment.

Background: Evidence-based recommendations do not adequately address the treatment of right heart thrombi in patients who present with acute symptomatic pulmonary embolism.Methods: This study included patients who had acute pulmonary embolism associated with right heart thrombi and participated in the Registro Informatizado de la Enfermedad TromboEmbólica registry. We assessed the effectiveness of anticoagulation versus reperfusion treatment for the outcomes of all-cause mortality, pulmonary embolism-related mortality, recurrent venous thromboembolism, and major bleeding rates through 30 days after initiation of pulmonary embolism treatment. We used propensity score matching to adjust for the likelihood of receiving reperfusion treatment.Results: Of 325 patients with pulmonary embolism and right heart thrombi, 255 (78%; 95% confidence interval, 74-83) received anticoagulation and 70 (22%; 95% confidence interval, 17-26) also received reperfusion treatment. Propensity score-matched pairs analyses did not detect a statistically lower risk of all-cause death (6.2% vs 14%, P = .15) or pulmonary embolism-related mortality (4.7% vs 7.8%; P = .47) for reperfusion compared with anticoagulation. Of the patients who received reperfusion treatment, 6.2% had a recurrence during the study follow-up period, compared with 0% of those who received anticoagulation (P = .049). The incidence of major bleeding events was not statistically different between the 2 treatment groups (3.1% vs 3.1%; P = 1.00).Conclusions: In patients with pulmonary embolism and right heart thrombi, no significant difference was found between reperfusion therapy and anticoagulant therapy for mortality and bleeding. The risk of recurrences was significantly higher for reperfusion therapy compared with anticoagulation. Right heart thrombi may not warrant riskier interventions than standard anticoagulation. [ABSTRACT FROM AUTHOR]

Background: For patients diagnosed with acute pulmonary embolism (PE), the prognostic significance of concomitant right heart thrombi (RHT) lacks clarity.Methods: We performed a meta-analysis of studies that enrolled patients with acute PE to assess the prognostic value of echocardiography-detectable RHT for the primary outcome of short-term all-cause mortality and the secondary outcome of short-term PE-related mortality. Unrestricted searches were conducted of PubMed and Embase from 1980 through January 31, 2016, and used the terms "right heart thrombi," "pulmonary embolism," and "prognos.*" A random effects model was used to pool study results; Begg rank correlation method was used to evaluate for publication bias; and I2 testing was used to assess for heterogeneity.Results: Six of 79 potentially relevant studies met the inclusion criteria (15,220 patients). Overall, 99 of 593 patients with echocardiography-detectable RHT died (16.7% [95% CI, 13.8-19.9]) compared with 639 of 14,627 without RHT (4.4% [95% CI, 4.0-4.7]). RHT had a significant association with short-term all-cause mortality in all patients (OR, 3.0 [95% CI, 2.2 to 4.1]; I2 = 20%) and with PE-related death (three cohorts, 12,955 patients; OR: 4.8 [95% CI, 2.0-11.3; I2 = 76%). Results were consistent for the prospective (two cohorts, 514 patients; OR, 4.8 [95% CI, 1.7-13.6]; I2 = 56%) and the retrospective (four cohorts, 14,706 patients; OR, 2.8 [95% CI, 2.1 to 3.8]; I2 = 0%) studies.Conclusions: In patients diagnosed with acute PE, concomitant RHT were significantly associated with an increased risk of death within 30 days of PE diagnosis.Trial Registry: PROSPERO registry; No.: CRD42016033960; URL: https://www.crd.york.ac.uk/prospero/. [ABSTRACT FROM AUTHOR]

We present two cases where successful thrombolysis of right heart thrombi and pulmonary embolism was accompanied by serious adverse events. In patient 1 with massive pulmonary thromboembolism, transesophageal ultrasound revealed large right atrial thrombus entrapped in a patent foramen ovale. Initial treatment with heparin was substituted with thrombolysis, which resulted in clinical improvement and dissolution of right heart thrombus but was followed by fatal intracerebral haemorrhage. In patient 2, thrombolysis caused mobilisation of thrombotic mass as evidenced by disappearance of thrombus on ultrasound. Massive pulmonary thromboembolism resulted in circulatory collapse. Short cardiopulmonary resuscitation restored spontaneous circulation and the patient recovered completely. [ABSTRACT FROM AUTHOR]

Background: Thrombolytic therapy is standard treatment in acute pulmonary thromboembolism (PTE) with hemodynamic instability. Although right heart thrombi (RHT) appear to increase mortality in acute PTE, large-scale studies of acute PTE with RHT are scarce., Methods and results: Patient data (from August 2005 to May 2014) obtained from post-marketing surveillance of thrombolytic therapy using a tissue-type plasminogen activator were analyzed retrospectively. Of the 2,698 confirmed cases of acute PTE who underwent echocardiographic assessment, 166 (6.2%) were diagnosed with RHT. PTE patients with RHT, compared with those without RHT, had higher rates of mortality (20.2% vs. 10.4%, P<0.001), hemodynamic instability (53.0% vs. 37.7%, P<0.001), and PTE recurrence (6.6% vs. 2.3%, P=0.003). When considering PTE-related hemodynamic severity (cardiopulmonary arrest/collapse, massive, submassive, and non-massive), mortality was significantly higher in patients with RHT in the massive (19.8% vs. 7.7%, P=0.002) and submassive (8.0% vs. 2.8%, P=0.018) groups, whereas no significant differences was found between those with and without RHT in the cardiopulmonary arrest/collapse (51.7% vs. 52.1%, P=0.960) and non-massive (1.6% vs. 0%, P=0.596) groups., Conclusions: PTE patients with RHT had higher mortality, severity, and PTE recurrence rates. RHT was particularly associated with worse outcomes in patients with massive or submassive PTE.