A challenging case of collapse with tri-fascicular block: from permanent pacemaker to thrombolysis

Br J Cardiol 2016;23:39doi:10.5837/bjc.2016.012 Leave a comment
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A 90-year-old man with a history of prostate cancer was admitted with haematuria and mild normocytic anaemia on routine blood tests. Baseline observations were normal and chest X-ray was unremarkable. Electrocardiogram (ECG) showed tri-fascicular block. He underwent successful bladder irrigation. Prior to discharge, he suffered a syncopal episode: ECG confirmed tri-fascicular block, for which he was discussed with the cardiology team for consideration of permanent pacemaker implantation. Pre-procedural transthoracic echocardiogram (TTE) revealed a large mobile thrombus attached to the tricuspid valve (TV) and extending to the right ventricle (RV), significant RV impairment and severe TV regurgitation (figure 1A–B). Following discussion between urology and cardiology teams and, in view of the significant risk of massive pulmonary embolism (PE), the patient underwent urgent thrombolysis. This was not complicated by significant haematuria. Post-intervention TTE demonstrated complete dissolution of the right-sided thrombus and mild TV regurgitation only (figure 1C–D). Warfarin was started and no further haematuria or syncope was reported on subsequent follow-up.

Figure 1. A. Pre-thrombolysis transthoracic echocardiogram. Technically difficult study: large mobile thrombus extending from the tricuspid valve into the right ventricle; dilated right heart chambers (with impaired right ventricular function). B. Pre-thrombolysis transthoracic echocardiogram: in addition to the findings described in panel A, colour flow shows a jet of severe tricuspid valve regurgitation. C. Post-thrombolysis transthoracic echocardiogram: complete dissolution of the right heart thrombus (with improved right ventricular function). D. Postthrombolysis
transthoracic echocardiogram: colour flow shows mild regurgitation only
Figure 1. A. Pre-thrombolysis transthoracic echocardiogram. Technically difficult study: large mobile thrombus extending from the tricuspid valve into the right ventricle; dilated right heart chambers (with impaired right ventricular function). B. Pre-thrombolysis transthoracic echocardiogram: in addition to the findings described in panel A, colour flow shows a jet of severe tricuspid valve regurgitation. C. Post-thrombolysis transthoracic echocardiogram: complete dissolution of the right heart thrombus (with improved right ventricular function). D. Postthrombolysis transthoracic echocardiogram: colour flow shows mild regurgitation only

A 90-year-old man with a history of prostate cancer was admitted with haematuria and mild normocytic anaemia on routine blood tests. Baseline observations were normal and chest X-ray was unremarkable. Electrocardiogram (ECG) showed tri-fascicular block. He underwent successful bladder irrigation. Prior to discharge, he suffered a syncopal episode: ECG confirmed tri-fascicular block, for which he was discussed with the cardiology team for consideration of permanent pacemaker implantation. Pre-procedural transthoracic echocardiogram (TTE) revealed a large mobile thrombus attached to the tricuspid valve (TV) and extending to the right ventricle (RV), significant RV impairment and severe TV regurgitation (figure 1A–B). Following discussion between urology and cardiology teams and, in view of the significant risk of massive pulmonary embolism (PE), the patient underwent urgent thrombolysis. This was not complicated by significant haematuria. Post-intervention TTE demonstrated complete dissolution of the right-sided thrombus and mild TV regurgitation only (figure 1C–D). Warfarin was started and no further haematuria or syncope was reported on subsequent follow-up.

Discussion

Right heart thrombus is a life-threatening condition commonly seen with structural heart disease, atrial fibrillation, devices in superior vena cava or right heart, thrombophilia and malignancy. It is associated with an incidence of PE of 97%,1 in-hospital mortality of 44.7%2 and mortality of 100%, if untreated.3 Treatment options include thrombolysis, anticoagulation, surgical or percutaneous thrombo-embolectomy, although evidence of optimal management is lacking.

This difficult case, complicated by haematuria, emphasises the successful outcome achieved with thrombolytic treatment. Thrombolysis presents the lowest mortality rate, and allows rapid improvement of pulmonary reperfusion, pulmonary hypertension and RV function and simultaneous dissolution of intra-cardiac thrombus, PE and venous thromboembolism.

Conflict of interest

None declared.

Key messages

  • Mortality associated with right heart thrombi is very high, regardless of the chosen treatment
  • Although there is no clear consensus for the preferred treatment, rapid diagnosis and treatment are essential
  • Thrombolysis is a fast and relatively simple treatment, particularly useful when surgical thrombo-embolectomy is contraindicated
  • Transthoracic echocardiography (TTE) is usually adequate for the diagnosis of right heart thrombus and has a sensitivity of 50–60%. However, it might underestimate the clot size. Trans-oesophageal echocardiography presents 80% sensitivity and 100% specificity for the detection of right heart thrombi
  • This case resulted in the successful treatment of a life-threatening condition, thanks to a multi-disciplinary approach with careful evaluation of treatment options, as well as of risks and benefits, which should always be encouraged in similar complex cases

References

1. Chartier L, Bera J, Delomez M et al. Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation 1999;99:2779–83. http://dx.doi.org/10.1161/01.CIR.99.21.2779

2. Torbicki A, Galie N, Covezzoli A et al. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol 2003;41:2245–51. http://dx.doi.org/10.1016/S0735-1097(03)00479-0

3. Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest 2002;121:806–14. http://dx.doi.org/10.1378/chest.121.3.80

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