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Successful Treatment of Right Heart Thromboemboli With IV Recombinant Tissue-Type Plasminogen Activator During Continuous Echocardiographic Monitoring^*

A Case Series Report

^* From the Division of Cardiology (Drs. Greco, Bisignani, Serafini, Guzzo, and Plastina), Ospedale Civile "Annunziata," Cosenza, Italy; and the Division of Cardiology (Dr. Stingone), Department of Medicine, University Federico II, Napoli, Italy.

Correspondence to: Francesco Greco, MD, Via Giostra Vecchia 2, 87100 Cosenza, Italy

Background and study objective: Echocardiographic detection of right heart thromboemboli (RHTE) during pulmonary embolism (PE) shows an uncommon but life-threatening event. The treatment of this condition is not well established. The aim of our study is to evaluate the efficacy and safety of recombinant tissue-type plasminogen activator (rt-PA) in treating RHTE.

Method: We performed a transthoracic echocardiogram within (mean ± SD) 120 ± 45 min from onset of symptoms on 30 consecutive patients with proven massive PE. Seven patients (23%) showed RHTE, four patients (57%) had cardiogenic shock; and all patients showed echocardiographic features of acute cor pulmonale. The seven patients with RHTE received an IV infusion of 100 mg rt-PA over a period of 2 h with continuous echocardiographic monitoring.

Results: We observed complete RHTE lysis at 45 to 60 min from the onset of rt-PA infusion and significant reductions at 2 h in the following: 14% in right ventricle (RV) end-diastolic diameter (reduction, 40.8 to 35 mm; p < 0.01); 12% in RV/left ventricular ratio (reduction, 0.83 to 0.73; p < 0.01); and 17% in tricuspid regurgitant flow velocity (reduction, 3.5 to 2.9 m/s; p < 0.01). The interventricular septal and RV wall motions improved. An excellent clinical outcome was achieved rapidly in all patients. No adverse events were recorded.

Conclusions: We demonstrated the rapid, effective, and safe action of rt-PA in RHTE resolution and an improvement in pulmonary perfusion. Our data confirm the important role of an early, systematic echocardiographic approach in order to detect RHTE quickly in patients with suspected massive PE.

Key Words: echocardiography • pulmonary embolism • recombinant tissue-type plasminogen activator • thrombus

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