alexa
Reach Us +44-1625-708989
Successful Treatment of Right Heart Thrombi and Acute Massive Pulmonary Embolism by Repeated Thrombolysis | OMICS International
ISSN: 2155-9880
Journal of Clinical & Experimental Cardiology

Like us on:

Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on Medical, Pharma, Engineering, Science, Technology and Business
All submissions of the EM system will be redirected to Online Manuscript Submission System. Authors are requested to submit articles directly to Online Manuscript Submission System of respective journal.

Successful Treatment of Right Heart Thrombi and Acute Massive Pulmonary Embolism by Repeated Thrombolysis

Marija Svetikiene1*, Vilius Janusauskas2, Justina Griciute1 , Rimgaudas Katkus2 , Donata Ringaitiene1 , Jurate Sipylaite1 , Kestutis Rucinskas2 and Pranas
Serpytis J2,3

1Center of Anesthesiology and Intensive Care, Vilnius University Hospital, Santariškių Clinics, Lithuania

2Clinic of Cardiovascular Diseases, Faculty of Medicine, Vilnius University, Lithuania

3Center Emergency Medicine, Faculty of Medicine, Vilnius University, Lithuania

*Corresponding Author:
Marija Svetikiene
Center of Anesthesiology and Intensive Care
Vilnius University Hospital
Santariškių Clinics
Lithuania
Tel: +370 61225352
E-mail: [email protected]

Received date: April 29, 2016; Accepted date: June 21, 2016; Published date: June 30, 2016

Citation: Svetikiene M, Janusauskas V, Griciute J, Katkus R, Ringaitiene D, et al. (2016) Successful Treatment of Right Heart Thrombi and Acute Massive Pulmonary Embolism by Repeated Thrombolysis. J Clin Exp Cardiolog 7: 451. doi:10.4172/2155-9880.1000451

Copyright: © 2016 Svetikiene M, et al. This is an open -access article distributed under the terms of the Creative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.



Visit for more related articles at Journal of Clinical & Experimental Cardiology

Abstract

We present the case of a 19 year old female who underwent a massive pulmonary embolism with thrombus in right ventricle (RV) and acute RV failure. Thrombolytic treatment had failed and repeated thrombolysis was given after 24 hours. Treatment was successful and on the eleventh day of hospitalization the patient was discharged. The current guidelines do not give clear directions for the management of patients with acute massive pulmonary embolism who do not respond to fibrinolytic therapy. A repeated thrombolysis could be an alternative treatment over surgical embolectomy for these patients.

Keywords

Massive pulmonary embolism; Right heart thrombi; Repeated thrombolysis

Introduction

Pulmonary embolism (PE) is a major cause of mortality, morbidity, and hospitalization in Europe [1-3]. In-transit right heart thrombi are a potentially life-threatening complication of pulmonary embolism [4]. There is little published evidence on the treatment of mobile masses in the right heart. In the current case, we report a potential treatment modality for this situation.

Clinical Case

A 19 year old presented to the emergency department with a 12- hour history of a general weakness, shortness of breath (walking distance reduced to 200 m), and chest pain, spreading to the left hand. On admission, the patient had symmetric pulses and blood pressures of 80/60 mmHg; jugular venous pressure was 18 mmHg; the radial and pedal pulses were intact and there was no edema or cyanosis. The patient’s respiratory rate was 28 breaths per minute. Air oxygen saturation with face-mask (6 L/min) was 98 percent; arterial blood gas analysis revealed hypoxemia (partial oxygen pressure (PO2) = 66 mmHg). The patient’s past medical history was unremarkable and included atopic dermatitis treated with topical means and use of hormonal contraceptive Belara (Ethinylestradiol/Chlormadinon 0,03/2 mg) over the past year. The electrocardiogram revealed normal sinus rhythm, normal axis, and normal intervals. Laboratory investigations showed increased lactate 2.61 mmol/l, troponin I 361.6 ng/l, D-dimer 16550 mcg/L, and brain natriuretic peptide 401.3 ng/l. There was no change in kidney and liver function.

The echocardiography showed RV twice bigger than left ventricle (LV); paradoxical intraventricular septal motion; reduced RV inotropy (fractional area change 20%). An agile (2.9 × 1.2 cm) mass—probable thrombus—was observed in the RV cavity between tricuspid valve (TV) chordae (Figure 1).

Contrast CT angiography has confirmed a massive pulmonary embolus in the main right pulmonary artery extending to the both lobar arteries and below (Figure 2), and thrombi bilaterally in common iliac veins.

The urgent thrombolysis was performed as the patient was hypotensive, tachycardic and hypoxemic. Alteplase was used. The dose of alteplase was calculated according to the manufacturer’s guidelines: 1.5 mg/kg in patients with a body weight below 65 kg. The patient’s weight was 40 kg and she was given 6 mg IV bolus followed by an infusion of 54 mg over two hours (in total, 60 mg). Thrombolysis was performed successfully with no complications. There was immediate clinical improvement after infusion of alteplase: the heart rate went down to 100 beats per minute and respiratory rate was reduced to 20 breaths per minute, yet the patient was still hypotensive and complained of shortness of breath. Echocardiography was repeated four hours after thrombolysis. There was reduction in the RV diameter; right atrium (RA)/RV max gradient was reduced from 50 mmHg to 25 mmHg, but thrombus was still present in the right ventricle. The patient had experienced no complications related to the thrombolysis but there was some effect after thrombolysis and the patient was reluctant to undergo surgical embolectomy; therefore repeated thrombolysis (alteplase 1 mg/kg/1 h) was performed six hours after the first procedure. After repeated thrombolysis, a further positive effect was observed: reduced shortness of breath and chest pain, and patients’ blood pressure increased to 100/60 mmHg. The patient was left on continuous heparin infusion (target APTT: 1.5–2 in normal range) for five days. After 48 hours, echocardiography showed no thrombus in RV left.

clinical-experimental-cardiology-echocardioscopy

Figure 1: Echocardioscopy, two chamber view, thrombus in RV.

clinical-experimental-cardiology-angiography

Figure 2: Contrast CT angiography. A. Sagittal plane; B. Transverse plane; C. Frontal plane Embolus in the main right pulmonary artery extending to the both lobar arteries and below.

Treatment with Xarelto (rivaroxaban) 15 mg–>30 mg was started after five days. On the eleventh day after thrombolysis, the patient was discharged home.

Discussion

Venous thromboembolism is the third most frequent cardiovascular disease, with an overall annual incidence of 100–200 per 100,000 inhabitants [5,6]. Patients may present with different extents of PE, and different symptoms. Treatment options depend on the patient’s clinical state and concomitant diseases (contraindications for thrombolysis). Intravenous anticoagulation with unfractionated heparin (UFH) is recommended for patients with suspected PE; thrombolysis is recommended for hypotensive patients or patients in hemodynamic shock. Surgical embolectomy is recommended for patients who have failed thrombolysis or in whom thrombolysis is contraindicated [1]. Mortality after systemic thrombolysis reaches up to 22.89 percent [7]; mortality following surgical embolectomy for acute pulmonary embolism reaches up to 27.2 percent [8]. Repeat thrombolysis is not recommended according to the current guidelines.

Patients with right ventricle embolus usually present with more severe symptoms and are more frequently treated using thrombolysis or surgical intervention [9]. In patients with mobile right heart thrombi, treatment selection is still unclear. In our case (patient with mobile mass in RV), the first dose of thrombolytic therapy gave a partial effect. The patient was not taken for surgical embolectomy as she was relatively stable and was not keen to undergo surgical intervention. A second dose of thrombolysis completely relieved the patient’s symptoms and hemodynamic state.

Two doses of thrombolysis have been reported in literature previously: van den Biggelaar et al. reported a clinical case of successful treatment of PE with repeated thrombolysis with alteplase at first and urokinase after two hours [10]. Spanodimos et al. reported a case of successful double thrombolysis with alteplase PE treatment [11].

The experience of repeated thrombolysis in massive PE is limited. The outcome of repeated thrombolysis was beneficial in this our case. The second dose of thrombolysis could be considered with expected good outcomes in some patients, but success of repeated thrombolysis in our case provides no guarantee of safety in other cases.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Article Usage

  • Total views: 9130
  • [From(publication date):
    June-2016 - Sep 20, 2019]
  • Breakdown by view type
  • HTML page views : 9022
  • PDF downloads : 108

Review summary

  1. Samuel
    Posted on Aug 03 2016 at 5:36 pm
    The authors reported a case of 19 year old female with massive pulmonary embolism, thrombus in right ventricle (RV) and acute RV failure. She was successfully treated with a repeated thrombolytic therapy. This an interesting case report. However, the first thrombolytic therapy dramatically reduced RV-RA maximal pressure gradient from 50 to 20 mmHg with significant improvement of vital signs. The paper is consise and important as it describes a therpeutic option for a serious condition, and it is important to expose the medical community to such an option.

Post your comment

captcha   Reload  Can't read the image? click here to refresh
Peer Reviewed Journals

Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals

Top