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CASE REPORT
Year : 2020  |  Volume : 30  |  Issue : 3  |  Page : 165-166

A floating right atrial and ventricular thrombus in a patient with syncope


1 Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan; Department of Internal Medicine, Cardiology, University of Leipzig - Heart Centre, Leipzig, Germany
2 Department of Internal Medicine, Cardiology, University of Leipzig - Heart Centre, Leipzig, Germany
3 Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan

Date of Submission15-Feb-2020
Date of Decision13-May-2020
Date of Acceptance02-Sep-2020
Date of Web Publication05-Nov-2020

Correspondence Address:
Abdullah Al-kasasbeh
Department of Internal Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcecho.jcecho_15_20

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  Abstract 


Here, we describe a rare echocardiographic finding of a floating right heart thrombus in an elderly woman who presented with an unexplained syncope. Our case demonstrates the pivotal role of echocardiography in the workup of patients admitted with syncope.

Keywords: Echocardiography, pulmonary embolism, right heart, syncope, thrombus


How to cite this article:
Al-kasasbeh A, Lurz P, Ibdah R, Rawashdeh SI, Khassawneh B. A floating right atrial and ventricular thrombus in a patient with syncope. J Cardiovasc Echography 2020;30:165-6

How to cite this URL:
Al-kasasbeh A, Lurz P, Ibdah R, Rawashdeh SI, Khassawneh B. A floating right atrial and ventricular thrombus in a patient with syncope. J Cardiovasc Echography [serial online] 2020 [cited 2020 Nov 24];30:165-6. Available from: https://www.jcecho.org/text.asp?2020/30/3/165/300083




  Introduction Top


We present a case of an elderly patient who presented with unexplained syncope and found to have a floating thrombus between the right atrium (RA) and right ventricle (RV) secondary to venous thromboembolic disease.


  Case Report Top


An 89-year-old female patient presented with a 12-h history of central heavy chest pain followed by three episodes of syncope. Each episode lasted about 30 s and followed by full recovery. Three weeks earlier, she noticed left leg swelling that resolved spontaneously. She denied headache, visual aura, nausea, cough, or hemoptysis. She has hypertension, paroxysmal atrial fibrillation, and a remote history of deep-vein thrombosis.

Physical examination on admission to the coronary care unit showed a well-looking elderly patient. Her heart rate was 81/min, blood pressure was 120/80 mmHg, respiratory rate was 18/min, and the oxygen saturation was 94% in room air. Heart examination showed normal heart sounds and no murmurs. Chest examination was within normal limits.

Her initial electrocardiogram showed normal axis, sinus rhythm, and nonspecific ST-T changes. Transthoracic echocardiography (TTE) showed a large longitudinal thrombus measuring 9.0 cm × 1.0 cm free floating between the RA and the RV [Video 1]

. Moreover, there was paradoxical septal motion and right heart dilatation [Video 2].

The end-diastolic RV dimensions were 50 mm at the base and 40 mm at the midlevel in the apical four-chamber view. The RA area measured 20 cm2. The patient had moderate tricuspid regurgitation with an estimated systolic pulmonary artery pressure of 70 mmHg. The RV function was severely impaired (tricuspid annular plane systolic excursion = 11 mm). The diameter of the inferior vena cava was 2.6 cm with <50% variation in the diameter with respiration. In a follow-up TTE 2 h later, the thrombus was no more visible [Video 3]

. A computed tomography angiography of the chest was done on the same day which showed bilateral central pulmonary emboli [Figure 1].
Figure 1: Contrast-enhanced computed tomography angiogram of the chest showing pulmonary embolism in the right main pulmonary artery and a filling defect in the left pulmonary artery branch

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The patient remained hemodynamically stable and had a PaO2 of 68 mmHg and oxygen saturation of 95% in room air. Doppler ultrasound study of the lower extremities showed a residual deep-vein thrombosis in the left posterior tibial vein. She received in-hospital intravenous unfractionated heparin. She declined further investigations to rule out malignancy or thrombophilia and was discharged after 4 days on rivaroxaban 15 mg twice daily for 21 days and then a lifelong therapy with 20 mg once daily.


  Discussion Top


Syncope was reported in 0.8% to 17.3% of patients with pulmonary embolism (PE).[1],[2],[3] While PE is an unlikely diagnosis in patients presenting to the emergency room with syncope,[4] one in six of the hospitalized patients with syncope had PE.[5],[6] Elevated troponin and the presence of dilated RV were predictors of having PE in patients admitted with syncope.[2] Furthermore, syncope in the context of PE is associated with increased 30-day mortality.[6]

Several mechanisms may explain why some patients with PE present with syncope. Massive PE may cause acute RV failure, impaired left ventricular filling, and consequently reduced cerebral perfusion.[1] A second mechanism that may be implicated is the presence of hemodynamically unstable tachydysrhythmias or bradydysrhythmias.[1] Finally, PE may trigger a vasovagal reflex that may lead to syncope on a neurogenic basis.[1] In this case, the most likely cause of syncope was an intermittent occlusion of the RV outflow tract through the floating thrombus with consequent impairment of the left ventricular filling, transient decrease in the cardiac output, and cerebral hypoperfusion.

Echocardiography has been utilized as a diagnostic and prognostic tool in patients with suspected PE.[7],[8] At least one study showed that while echocardiographic finding of right heart thrombi is uncommon in patients with acute PE, its presence is associated with worse prognosis.[9]

In this case, the reported echocardiographic findings of a mobile right heart thrombus highlight the importance of performing TTE, as a rapid and noninvasive tool, in evaluating patients who are admitted with an otherwise unexplained syncope.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Keller K, Hobohm L, Münzel T, Ostad MA, Espinola-Klein C. Syncope in haemodynamically stable and unstable patients with acute pulmonary embolism-Results of the German nationwide inpatient sample. Sci Rep 2018;8:15789.  Back to cited text no. 1
    
2.
Ammar H, Ohri C, Hajouli S, Kulkarni S, Tefera E, Fouda R, et al. Prevalence and predictors of pulmonary embolism in hospitalized patients with syncope. South Med J 2019;112:421-7.  Back to cited text no. 2
    
3.
Oqab Z, Ganshorn H, Sheldon R. Prevalence of pulmonary embolism in patients presenting with syncope. A systematic review and meta-analysis. Am J Emerg Med 2018;36:551-5.  Back to cited text no. 3
    
4.
Badertscher P, du Fay de Lavallaz J, Hammerer-Lercher A, Nestelberger T, Zimmermann T, Geiger M, et al. Prevalence of pulmonary embolism in patients with syncope. J Am Coll Cardiol 2019;74:744-54.  Back to cited text no. 4
    
5.
Prandoni P, Lensing AW, Prins MH, Ciammaichella M, Perlati M, Mumoli N, et al. Prevalence of pulmonary embolism among patients hospitalized for syncope. N Engl J Med 2016;375:1524-31.  Back to cited text no. 5
    
6.
Roncon L, Zuin M, Casazza F, Becattini C, Bilato C, Zonzin P. Impact of syncope and pre-syncope on short-term mortality in patients with acute pulmonary embolism. Eur J Intern Med 2018;54:27-33.  Back to cited text no. 6
    
7.
Bikdeli B, Lobo JL, Jiménez D, Green P, Fernández-Capitán C, Bura-Riviere A, et al. Early use of echocardiography in patients with acute pulmonary embolism: Findings from the RIETE registry. J Am Heart Assoc 2018;7:e009042.  Back to cited text no. 7
    
8.
Leibowitz D. Role of echocardiography in the diagnosis and treatment of acute pulmonary thromboembolism. J Am Soc Echocardiogr 2001;14:921-6.  Back to cited text no. 8
    
9.
Torbicki A, Galié N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ, et al. Right heart thrombi in pulmonary embolism: Results from the international cooperative pulmonary embolism registry. J Am Coll Cardiol 2003;41:2245-51.  Back to cited text no. 9
    


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