Prognostic significance of free-floating right heart thromboemboli in acute pulmonary embolism

 

 Buy Article Permissions and Reprints

Summary

The exact prevalence of mobile right heart thromboemboli (RHTh) in patients with pulmonary embolism (PE) is unknown, depending upon PE severity and the use of early echocardiography. Similarly, the mortality rate is variable, though RHTh detection appears to substantially increase the risk of death in patients with PE. The aim of this study was to assess the prevalence of RHTh in different risk categories in a wide series of patients with PE, and to analyse the effect of RHTh on in-hospital mortality. Among 1,716 patients enrolled in the Italian Pulmonary Embolism Registry, 1,275 (13.3% at high risk, 59.3% at intermediate risk and 27.4% at low risk) had echocardiography within 48 hours from hospital admission and entered the study. Overall, RHTh were detected in 57 patients (4.5%, at admission echocardiography in 88%): in 27/169 (16%) high-risk, in 29/756 (3.8%) intermediate-risk and 1/350 (0.3%) low-risk patients, respectively. At multivariate analysis, only advanced age (odds ratio [OR] 1.61, 95% confidence [CI] 1.27–2.03, p<0.0001), high-risk category (OR vs low-risk category 37.82, 95% CI 11.26–127.06, p<0.0001) and recurrent PE (OR 45.92, 95%CI 15.19–139.96, p<0.0001) showed a statistically significant effect on mortality. The presence of RHTh significantly increased the risk of dying (OR 3.89, 95%CI 1.98–7.67, p=0.0001) at univariate analysis, but this result was not mantained in the multivariate model (OR 1.64, 95%CI 0.75–3.60, p=0.216). In conclusion, though patients with RHTh had a more severe presentation of PE, this study did not detect an association between RHTh and prognosis.

• References

• 1 Franzoni P, Cuccia C, Zappa C. et al. Tromboembolo migrante nella cavitä car-diache destre in corso di embolia polmonare. G Ital Cardiol 1989; 19: 7-16.
  PubMedGoogle Scholar
• 2 Pierre-Justin G, Pierard LA. Management of mobile right heart thrombi: a prospective series. Int J Cardiol 2005; 99: 381-388.
  CrossrefPubMedGoogle Scholar
• 3 Torbicki A, Galié 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: 2245-2251.
  CrossrefPubMedGoogle Scholar
• 4 Casazza F, Bongarzoni A, Centonze F. et al. Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism. Am J Cardiol 1997; 79: 1433-1435.
  CrossrefPubMedGoogle Scholar
• 5 Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest 2002; 121: 806-814.
  CrossrefPubMedGoogle Scholar
• 6 Ferrari E, Benhamou M, Berthier F. et al. Mobile thrombi of the right heart in pulmonary embolism. Delayed disappearance after thrombolytic treatment. Chest 2005; 127: 1051-1053.
  CrossrefPubMedGoogle Scholar
• 7 Cuccia C, Campana M, Franzoni P. et al. Effectiveness of intravenous rt-PA in the treatment of massive pulmonary embolism and right heart thromboembol-ism. Am Heart J 1993; 126: 468-472.
  CrossrefPubMedGoogle Scholar
• 8 Greco F, Bisignani G, Serafini O. et al. Successful treatment of right heart thromboemboli with IV recombinant tissue-type plasminogen activator during continuous echocardiographic monitoring: a case series report. Chest 1999; 116: 78-82.
  CrossrefPubMedGoogle Scholar
• 9 Chartier L, Béra J, Delomez M. et al. Free-floating thrombi in the right heart. Diagnosis, management and prognostic indexes in 38 consecutive patients. Circulation 1999; 99: 2779-2783.
  CrossrefPubMedGoogle Scholar
• 10 The European Cooperative Study on the clinical significance of right heart thrombi. European Working Group on Echocardiography. Eur Heart J 1989; 10: 1046-1059.
  CrossrefPubMedGoogle Scholar
• 11 Kinney REL, Wright RJ. Efficacy of treatment of patients with echocardio-graphically detected right-sided heart thrombi. Am Heart J 1989; 118: 569-573.
  CrossrefPubMedGoogle Scholar
• 12 Mollazadeh R, Ostovan MA, Ardekani ARA. Right cardiac thrombus in transit among patients with pulmonary thromboemboli. Clin Cardiol 2009; 32: 27-31.
  CrossrefPubMedGoogle Scholar
• 13 Casazza F, Becattini C, Bongarzoni A. et al. Clinical features and short term outcomes of patients with acute pulmonary embolism. The Italian Pulmonary Embolism Registry. Thromb Res 2012; 130: 847-852.
  CrossrefPubMedGoogle Scholar
• 14 Torbicki A, Perrier A, Konstantinides S. et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008; 29: 2276-2315.
  CrossrefPubMedGoogle Scholar
• 15 Konstantinides S, Geibel A, Heusel G. et al. Management Strategies and Prognosis of Pulmonary Embolism-3 Trial Investigators. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med 2002; 347: 1143-1150.
  CrossrefPubMedGoogle Scholar
• 16 Douketis JD, Shu Gu C, Schulman S. et al. The risk for fatal pulmonary embolism after discontinuing anticoagulant therapy for venous thromboembolism. Ann Int Med 2007; 147: 766-774.
  CrossrefPubMedGoogle Scholar
• 17 Jaff MR, McMurtry MS, Archer SL. et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic throm-boembolic pulmonary hypertension. A scientific statement from the American Heart Association. Circulation 2011; 123: 1788-1830.
  CrossrefPubMedGoogle Scholar
• 18 Cromwell RH, Adams GS, Koilpillai CJ. et al. In vivo right heart thrombus. Precursor of life-threatening pulmonary embolism. Chest 1988; 94: 1236-1239.
  CrossrefPubMedGoogle Scholar