Management of mobile right atrial thrombi: a therapeutic dilemma.
BACKGROUND
Mobile right atrial thrombus is an uncommon finding on two-dimensional (2D) echocardiography. Therapeutic alternatives include systemic heparinization, systemic or local thrombolysis, and surgical removal. We report our clinical experience in six patients over a 3-year period (6000 echocardiograms) at a tertiary care referral center.


METHODS
There were four men and two women with a mean age of 63 years (range: 47 to 73 years). Indications for echocardiography consisted of progressive dyspnea and chest pain in five patients and syncope with chest pain in one patient.


RESULTS
All were observed to have a mobile thrombus in the right atrium. Ventilation perfusion (V/Q) scanning confirmed V/Q mismatch in all patients. Subsequent echocardiography (minutes to 1 day later) in three patients demonstrated absence of the thrombus suggesting pulmonary embolization. One patient died during transesophageal echocardiography (TEE) and autopsy confirmed a large pulmonary embolization in the main pulmonary artery. Treatment consisted of heparinization in 3 patients, systemic thrombolysis in 1 patient, and surgical removal of the thrombus in 1 patient. At surgery, a long serpiginous thrombus was seen in the right atrium, tethered to a fenestrated eustachian valve. There were 3 deaths: 1 patient treated with heparin; 1 patient treated with thrombolysis; and 1 during TEE. Two of the three patients treated with heparin and one patient undergoing surgical removal survived hospitalization.


CONCLUSIONS
Mobile thrombus in the right atrium is an unusual echocardiographic finding. It portends a poor prognosis with death due to pulmonary embolism.
Shah
C P
CP
Division of Cardiology and Cardiac Surgery, University Hospital, London, Canada.
Thakur
R K
RK
Ip
J H
JH
Xie
B
B
Guiraudon
G M
GM
D000368:Aged; D004452:Echocardiography; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006325:Heart Atria; D006331:Heart Diseases / Q000000981:diagnostic imaging* / Q000628:therapy*; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D017131:Thrombectomy; D015912:Thrombolytic Therapy; D013927:Thrombosis / Q000000981:diagnostic imaging* / Q000628:therapy*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use
D005343:Fibrinolytic Agents; D006493:Heparin; D010959:Tissue Plasminogen Activator