Intracardiac thrombus-in-transit: a ticking time bomb

SESSION TITLE: Unique, Unusual, and Unsuspecting Pulmonary Emboli SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: An intracardiac thrombus-in-transit is a rare and life-threatening condition that might lead to a pulmonary embolism. Management of a thrombus-in-transit is crucial and time sensitive as failure to treat adequately can lead to devastating consequences. There are currently few treatment options described, but the best one remains unknown. Here, we present a case of a patient with a large intracardiac right-sided thrombus-in-transit who successfully underwent aspirational thrombectomy. CASE PRESENTATION: A 74-year-old female with congestive heart failure, essential hypertension, end-stage renal disease on hemodialysis, and recent upper gastrointestinal bleeding presents with progressively worsening weakness and hypotension. Patient was hypotensive requiring pressor support and required 6 liters supplemental oxygen. Physical exam revealed a thin, frail female without any significant cardiac, pulmonary or extremity findings. Patient was discharged from the hospital 1 week ago after being treated for pneumonia. Upper extremity ultrasound during the previous admission showed right brachial vein thrombosis. Patient was not started on anticoagulation due to recent life-threatening gastrointestinal bleeding. Laboratory data during current admission showed elevated beta natriuretic peptide 14220 pg/ml, D-dimer 12200 ddu, and troponin 1120 ng/l. Computed tomographic imaging of the chest showed 3.9 cm right atrial density consistent with a thrombus-in-transit and no evidence of pulmonary embolism. Transthoracic echocardiography confirmed the right atrial thrombus and failed to show any evidence of right or left ventricular dysfunction. Patient was started on therapeutic anticoagulation with close monitoring of hemoglobin. Patient underwent catheter-assisted aspirational thrombectomy. Patient tolerated the procedure well and repeat imaging showed resolution of the thrombus. DISCUSSION: A clot or a thrombus-in-transit occurs in 4% of patients with PE and can be seen on imaging as a freely mobile, echogenic mass in the right atrium or right ventricle. Patients with this condition have a mortality of up to 25% since the risk of embolization to the pulmonary artery is high. Studies show that the risk of mortality is three times higher with a concurrent clot-in-transit and PE than a clot-in-transit alone. The best imaging modality to view clots in the right heart is a transthoracic echocardiogram, as it can also be used to assess right ventricular strain. After the clot is identified, the therapeutic options include anticoagulation, systemic thrombolysis, catheter-directed thrombolysis and thrombectomy. Current studies show lower mortality in patients who were given systemic thrombolytics compared to anticoagulation or thrombectomy. Not much data is available regarding the role of other treatment modalities CONCLUSIONS: An intracardiac thrombus-in-transit is a rare but fatal condition. When encountered, immediate management with thrombolytic therapy can be life-saving. If thrombolysis is contraindicated, as in our patient, thrombectomy can be pursued. Given the need for urgent treatment, it is essential for clinicians to know about the presentation, findings, and management options for this rare but life-threatening condition REFERENCE #1: Egolum, U. O., Stover, D. G., Anthony, R., Wasserman, A. M., Lenihan, D., & Damp, J. B. (2013). Intracardiac thrombus: diagnosis, complications and management. The American journal of the medical sciences, 345(5), 391–395. https://doi.org/10.1097/MAJ.0b013e318272b0b0 REFERENCE #2: Nuñez, R., Sanchez, J. A., Berber, S., Loaiza, F., Nuñez, J. G., Arias, S., & Almeida, E. (2021). Case report: Thrombus in transit-a cause of impending paradoxical embolism. European heart journal. Case reports, 5(2), ytaa580. https://doi.org/10.1093/ehjcr/ytaa580 REFERENCE #3: Dhulipala, V. R., Fayoda, B. O., Kyaw, H., & Ayala-Rodriguez, C. (2020). Thrombus in Transit: Extract or Dissolve?. Cureus, 12(8), e9550. https://doi.org/10.7759/cureus.9550 DISCLOSURES: No relevant relationships by Asad Chohan No relevant relationships by Saiara Choudhury No relevant relationships by Austin Makadia No relevant relationships by Vishesh Persaud No relevant relationships by Abhay Vakil