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* From the Cardiology Department, Pasteur University Hospital, Nice, France.
Correspondence to: Emile Ferrari, MD, Cardiology Department, Pasteur University Hospital, 30 Ave de la Voie Romaine, Nice 06002, France; e-mail: ferrari.e{at}chu-nice.fr
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Abstract |
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Methods and results: Of a series of 343 patients who had been hospitalized for PE in our department, echocardiography performed on hospital admittance showed a mobile clot in the RH in 18 patients (mobile clot incidence, 5.2%). This subgroup of 18 patients presented with a more severe form of PE than the 325 patients without mobile clots in the RH. In our series, 16 patients were treated with thrombolytic agents. Close echocardiography monitoring showed the outcomes of these mobile clots during and after TT. In 50% of cases, the clot disappeared rapidly in < 2 h after the end of TT. In 50% of the remaining cases, the clot disappeared later, half within 12 h following the completion of TT, and the other half within 24 h. All patients were alive on day 30 without any clinical sequellae.
Conclusion: In these particular forms of PE with mobile clots in the RH, the short time lag required to disperse the clot after TT makes it imperative to delay any decision about new aggressive therapy.
Key Words: echocardiography • pulmonary embolism • thrombolysis
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Introduction |
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TOPAbstractIntroductionAim of the StudyMaterials and MethodsResultsDiscussionConclusionReferences |
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Aim of the Study |
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TOPAbstractIntroductionAim of the StudyMaterials and MethodsResultsDiscussionConclusionReferences |
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Materials and Methods |
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TOPAbstractIntroductionAim of the StudyMaterials and MethodsResultsDiscussionConclusionReferences |
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TTE was performed (Sonos 5000; Hewlett Packard; Palo Alto, CA) by experienced operators. In order to confirm the diagnosis of these mobile clots in the RH, all TTE procedures were taped and reviewed by one of us (E.F.) in a blind manner. The clot was thus characterized by its appearance, size, and mobility. All patients had office follow-up at 1 month.
Statistical Analysis
Data were expressed as the mean ± SD. Differences for continuous variables between patients with and without RH clots were assessed by Student t test. Values of p < 0.05 were considered to be statistically significant.
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Results |
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In contrast, when examining PE severity criteria, a comparison between the two groups pinpointed a more severe form of PE when RH clot was present (Table 1 ). Indeed, heart rate, systolic pulmonary pressure assessed by echocardiography, and right ventricle/left ventricle diameter ratio were higher, while BP was lower in the group of patients presenting with RH clot (p < 0.05 for all four criteria).
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Treatments Performed
For the patient with the clot trapped in the foramen ovale, surgical removal was chosen. This patient had been hospitalized 3 days previously for a stroke. A systematic echocardiography performed at day 3 showed enlarged RH cavities and the clot trapped in the foramen ovale. Given the threatening nature of the clot, the patient was operated on.
The surgical procedure involved removing the clot and closing the foramen ovale. Despite the recent stroke, the outcome was favorable. In particular, there was no worsening of the patient’s neurologic condition.
One patient received treatment with IV heparin alone. For this patient, the clot was still present on day 5 and had disappeared by day 6, while echocardiography showed a decrease in systolic pulmonary pressure (from 54 to 42 mm Hg) and a decrease in right ventricle diastolic size (from 38 to 31 mm) with a concomitant improvement in right ventricle hemodynamics.
The remaining 16 patients received TT (alteplase, 10 mg as a bolus then 90 mg during a 2-h infusion). For these 16 patients who had been treated with thrombolytic agents, the first control echocardiogram, which was performed on average 2 h after the end of TT, showed the disappearance of the RH clot in 8 patients (50%). For four other patients (25%), the clot was still present with no modification of echocardiographic features but had disappeared at the second control echocardiogram within 12 h. It could not be determined exactly when the RH clots disappeared between hour 4 and hour 12.
For the remaining four patients (25%), the clot was still present at hour 4 and hour 12 but had disappeared by the time of hour 24 control echocardiogram. It should be noted that, in all cases, the control echocardiogram that had been performed before the disappearance of the clot showed a marked improvement in RH hemodynamic status with a decrease in the right ventricle/left ventricle diastolic diameter ratio (from 0.86 ± 0.11 to 0.65 ± 0.12, respectively) and a decrease in systolic pulmonary pressure (from 69 ± 12 to 48 ± 11 mm Hg, respectively).
On day 30, all patients were alive with no sequellae from their PE. None of these patients presented clinical signs of PE recurrence.
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Discussion |
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In an ancillary study using data from the International Cooperative Pulmonary Embolism Registry,6 Torbicki et al2 reported an incidence of 4%, which would decrease to 3.6% if we did not take into account those patients with central lines and pacemakers who obviously fall into a different category. Other studies,3 including those with patients experiencing more severe forms of PE (eg, patients who have been admitted to critical care units), have reported a higher incidence of these mobile clots in the RH.
It seems that the presence of RH clots has prognostic significance, predicting a mortality rate that is higher than the average. In a metaanalysis including all major reported cases in the literature up to 2002, Rose et al4 reported a 27% mortality rate.
In our study, we confirmed the correlation between the presence of an RH clot and the severity of the PE described in prior studies.23 This correlation probably explains the worse prognosis of these forms of PE. It is possible that the migration of these clots to the lung is temporarily slowed down by high pulmonary pressure, low cardiac output, and considerable tricuspid regurgitation, which may result in the clot remaining in the right atrium.
Obviously, the echocardiographic features of the clots we described, in particular their appearance and dimensions, represent a real model of a peripheral vein and argue in favor of in-transit clots rather than in situ clots, which may sometimes occur under conditions of low cardiac output.7
At the present time, there is no consensus on how to treat patients with PE and associated RH clots.8 The metaanalysis published in 1989 by Kinney and Wright9 showed no advantage for any treatment option used, namely, heparin, TT, or surgery. However, the more recent metaanalysis published by Rose et al4 pointed to a better outcome with TT. It should be mentioned that in the data from the study by Torbicki et al,2 the delay between the presumed onset of symptoms and hospitalization was shorter in patients with those forms of PE with mobile clots in the RH (2.2 vs 4.5 days, respectively). This may account, in part, for the favorable result when TT is used. In our study, although we did not perform hemodynamic measurements, the 50% rate of RH clot disappearance after 2 h seems a quite favorable response compared to the expected TT efficacy.1011
In our series, in addition to the very good results obtained with TT, we showed that mobile clots may persist in half of the patients treated in the hours following the end of TT without the result being prejudicial. This information is clinically relevant. It suggests that the persistence of the clot during the hours following TT should not result in a hasty decision to embark on a new strategy (eg, TT or a surgical option).
Our study did not allow us to assess whether disappearance of the clot was due to dissolution by TT or to migration to the pulmonary arteries. In the literature, some data12 favor dissolution of these clots by TT in the RH. However, some particular cases1314 documented the migration of these clots to the lung. The findings of our study argue in favor of the latter result. The improvement of cardiac output and the decrease in RH afterload and pulmonary pressure caused by TT may have finally induced migration of the clot. Dissolution of the clot in the RH, which probably formed prior to those already located in the lung, is a less likely hypothesis. In particular, in our study, the unchanged echocardiographic features of the clot after the maximal peak of thrombolytic efficacy argues against dissolution.
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Conclusion |
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Footnotes |
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Received for publication January 5, 2004. Accepted for publication September 17, 2004.
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References |
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