Detection of central pulmonary artery thromboemboli by transesophageal echocardiography in patients with severe pulmonary embolism.

Transthoracic echocardiography generally provides only indirect signs of pulmonary embolism. In contrast, with transesophageal echocardiography the thromboembolus itself can be visualized in the central parts of the pulmonary artery. The aims of our study were to evaluate, first, the incidence of central pulmonary artery thromboemboli in patients with severe pulmonary embolism, and second, the accuracy of the echocardiographic diagnosis. Our study group comprised 60 patients with proved severe pulmonary embolism. All patients were examined by transthoracic and transesophageal echocardiography. The echocardiographic findings concerning the absence or presence of central pulmonary artery thromboemboli were compared with the results of different reference methods. Central pulmonary thromboemboli were found in 35 patients (58.3%) by echocardiography. Two types of thrombus were differentiated. Type A is a long, highly mobile thrombus, and type B is an immobile wall-adherent thrombus. In comparison with the reference methods, we determined a sensitivity of 96.7% and a specificity of 88% for the echocardiographic detection of central pulmonary artery thromboemboli in patients with severe pulmonary embolism. Transesophageal echocardiography seems to be a useful method for the diagnosis of severe pulmonary embolism. In our series, central pulmonary artery thromboemboli were present in more than half of the patients. In these cases, transesophageal echocardiography can clarify the diagnosis within a few minutes without further invasive diagnostic procedures.     

Right atrial ‘thrombus in transit’ and atrial septal defect in a 70-year-old man: cardioembolic source of pulmonary and paradoxical cerebral embolization

A 70-year-old man was admitted with sudden onset of dyspnea, near syncope and left hemiparesis. Clinical examination, blood gas analysis, ECG and the chest X-ray were consistent with pulmonary embolism. Transthoracic echocardiography (TTE) revealed right atrial free-floating thrombus, large atrial septal defect (ASD), right heart enlargement and pulmonary artery hypertension. Anticoagulation therapy was initiated immediately, soon after thrombolytic therapy was started but the patient died due to possible pulmonary or cerebral embolization. We underscore rapid diagnosis by TTE that revealed right heart thrombus in transit and large ASD.     

Crossing atrial thrombus in a patient with recurrent pulmonary embolism

OBJECTIVES: To report the detection of a thrombus entrapped in a patent foramen ovale by echocardiography in a patient with recurrent pulmonary embolism. DESIGN: Case report. SETTING: Intensive care unit of a university hospital. PATIENT: A 62-yr-old man with initial deep venous thrombosis and recurrent minor pulmonary embolism followed by a severe embolic event with transitory hemiparesis 10 days after prostatectomy. INTERVENTION: Systemic anticoagulation, surgical removal of a crossing atrial thrombus, closure of a patent foramen ovale, and venous thrombectomy. MEASUREMENTS AND MAIN RESULTS: Transesophageal echocardiography revealed a large thrombus entrapped in a patent foramen ovale with portions in all four heart chambers. Intraoperatively, a 19-cm-long thrombus, shaped like the pelvic veins, was found. The patient was successfully weaned from cardiopulmonary bypass, requiring temporary positive inotropic support because of right ventricular dysfunction. Within 24 hrs of the operation, the patient was discharged to the intermediate care unit. CONCLUSIONS: Recurrent pulmonary embolism can potentially result in paradoxic embolism in patients with a patent foramen ovale. In such patients, it may be crucial to monitor right ventricular function and exclude right-to-left shunts by transesophageal echocardiography, regardless of clinical symptoms. The patent foramen ovale should be closed. This case emphasizes an important indication for transesophageal echocardiography in critically ill patients.     

Acute myocardial infarction caused by embolism of thrombus in the right coronary sinus of Valsalva: a case report and review of the literature.

A 56-year-old man presented with sustained chest pain. Coronary angiography revealed total occlusion of the distal right coronary artery and left anterior descending branch. Left ventriculography depicted a mobile mass in the right sinus of Valsalva originating from the ostium of the right coronary artery. Transesophageal echocardiography (TEE) showed a mobile mass in the sinus of Valsalva and another mobile mass in the aortic arch. The mass at the right sinus of Valsalva was surgically resected, and histologic examination revealed an organized thrombus. Coagulation study showed protein S deficiency. This is the first case of acute myocardial infarction as a result of multiple coronary embolism caused by thrombosis in the right sinus of Valsalva with a second aortic arch thrombosis, contributed by protein S deficiency.     

Multiple aortic thrombi associated with protein C and S deficiency

We describe a woman with an unusual case of thromboembolism of the mesenteric artery in whom multiple thrombi were subsequently found in the aorta and right heart chambers on transesophageal echocardiography. Further evaluation revealed a deficiency of protein C and S plasma proteins, inhibitors of the clotting system. The patient was treated successfully with systemic anticoagulation. Aortic thrombus is common in the setting of underlying atherosclerosis. However, the association of aortic thrombus with a deficiency of protein C and S is rare. To our knowledge, this is the first reported case of mural thrombus of the thoracic aorta associated with combined protein C and S deficiency. Our report underscores the important role of transesophageal echocardiography in the evaluation of patients with arterial thromboembolism.     

Impending paradoxical embolus: Clinical imaging and successful surgical treatment

In a patient with pulmonary emboli, transesophageal echocardiography showed a thrombus straddling the foramen ovale (impending paradoxical embolism). Proximal pulmonary emboli were visualized by spiral computed tomography and subsequent surgical treatment, consisting of removal of intracardiac clot, closure of the open foramen ovale and pulmonary embolectomy, was successful.     

McConnell's sign: Echocardiography in the management of acute pulmonary embolism

Management of acute pulmonary embolism depends immensely on rapid diagnosis and early intervention. Transthoracic echocardiography has gained favorability in scenarios where diagnostic computed tomography angiography is not feasible. McConnell''s sign, an echocardiographic finding of segmental right ventricular wall‐motion abnormality with apical sparing, is highly specific and may guide therapeutic intervention. We present the case of a 59‐year‐old man who was found to have acute pulmonary embolism with obstructive shock, managed successfully with thrombolytic therapy after identification of McConnell''s sign. We review current literature and develop a framework for the integration of echocardiography into the multimodal approach to management.     

Cerebral infarction following thrombolysis for massive pulmonary embolism

A 29-year-old male developed a fatal stroke 6 h after successful thrombolysis for massive pulmonary embolism. Autopsy showed thrombus protruding through a patent foramen ovale (PFO). A strand of thrombus extended from the aortic arch into the left common carotid artery. The brain showed extensive infarction of the left fronto-parietal area. Thrombolysis caused initial disintegration of the embolism. It is likely that thrombolysis caused fragments of clot to later break lose and embolise into the cerebral circulation. We discuss the need for risk stratification in patients who present with massive pulmonary embolism and PFO.     

Right atrial thrombus formation associated with central venous catheters utilization in hemodialysis patients

Objective To report five patients on hemodialysis via an indwelling central venous catheter who developed a thrombus located exclusively on the right atrial wall opposing the emptying site of the superior vena cava and to determine the possible cause of this location.Design Transthoracic echocardiography was performed in four of the patients as work-up for suspected endocarditis or pulmonary embolism and in one patient for syncope evaluation. The right atrial clots were confirmed in all the patients by transesophageal echocardiography.Design and setting General intensive care unit of a university hospital, tertiary referral center.Patients Five patients with end-stage chronic renal failure on hemodialysis via subclavian or internal jugular vein catheter.Interventions Three of these patients underwent surgical thrombectomy, and two others were medically treated.Measurements and results The clots were 2–4 cm in length and three of them were infected. Two of the three surgically treated patients and one of the two medically treated patients died. All the patients had the catheter tip in the right atrium, in two of them the bent catheter rubbed the atrial endocardium, and in all the cases the clot was located on the atrial free wall facing the superior vena cava emptying.Conclusions We postulate that the mechanism of thrombus formation at this location is related to friction of the catheter on the atrial endocardium, and therefore positioning the distal segment of the central venous catheters in the right atrium should be avoided.     

The role of echocardiography and venous ultrasonography in the diagnosis of acute pulmonary thromboembolism

Patients with pulmonary embolism (PE) are undergoing echocardiography and venous ultrasonography with increasing frequency. Echocardiography is ideal because it is readily available and is useful for the differential diagnosis in hemodynamically unstable patients. Although predominantly employed to characterize RV pressure overload, echocardiography may detect right heart thrombus or may provide alternative diagnosis. Echocardiography also is useful in assessing the prognosis of patients as well as their response to therapy. Right ventricular hypokinesis, a patent foramen ovale, and right heart thrombus are markers identifying patients at risk for death. PE and deep vein thrombosis are different clinical manifestations of a common disease entity. Venous ultrasonography may reduce pulmonary angiography in patients with non-diagnostic lung scan.     

超声检查在急性肺栓塞诊断中的价值

目的 探讨超声检查在急性肺栓塞诊断中的价值。方法 对临床综合诊断为肺栓塞的82例患者行经胸超声心动图和周围血管超声检查。结果 超声心动图发现右房内血栓1例，肺动脉干或左、右肺动脉栓塞7例，典型右心负荷过重和肺动脉高压25例。周围血管超声发现下肢深静脉和（或）髂静脉内血栓39例。结论 超声检查是急性肺栓塞影像学诊断的首选，是急诊情况下重要、实用、及时的诊断方法，对临床决策有较大帮助。     

Paradoxical embolism in the left main coronary artery: diagnosis by transesophageal echocardiography

We describe a patient with a paradoxical coronary embolism diagnosed by transesophageal echocardiography. The patient developed a stroke followed by a myocardial infarction. Coronary angiography showed an obstruction of the left main coronary artery. Transesophageal echocardiography showed the mechanism of the neurologic and cardiac events to be a paradoxical embolism. Emergency surgical retrieval of the thrombus lodged in the left main coronary ostium and of a separate thrombus traversing a patent foramen ovale was performed. To our knowledge, direct visualization of the paradoxical coronary embolism by echocardiography has not been reported previously. We discuss mechanisms responsible for paradoxical coronary embolism and review the literature pertaining to this condition.     

Transesophageal echocardiography for the diagnosis of pulmonary embolism with acute cor pulmonale: a comparison with radiological procedures

Objective: The goal of the study was to assess prospectively the value of transesophageal echocardiography (TEE) for the diagnosis of massive pulmonary embolism complicated by acute cor pulmonale. Design: A prospective study conducted on 44 consecutive patients. Setting: A general intensive care unit (ICU) of a university hospital. Patients and methods: Between May 95 and October 96, 44 consecutive patients with clinically suspected acute pulmonary embolism underwent transthoracic echocardiography (TTE), completed by TEE when acute cor pulmonale was present (30 patients). The results of the echocardiographic studies were compared with radiological investigations by helical CT or contrast angiography. Results: The high sensitivity and specificity of the presence of acute cor pulmonale on TTE for the diagnosis of pulmonary embolism was confirmed. Nineteen patients only underwent TEE. The sensitivity and the specificity of TEE in detecting a proximal pulmonary embolism were 84 % and 84 %, respectively. Its main limitation concerned the left pulmonary artery, in which only one thrombus was visualized by TEE whereas six were present on helical CT, and lobar pulmonary arteries which could not be visualized with TEE. Thus, the overall sensitivity of TEE for the detection of pulmonary embolism with acute cor pulmonale was only 58 %. Conclusion: In comparison with radiological procedures, TEE had limited accuracy for detecting pulmonary embolism with acute cor pulmonale. When the pulmonary embolism was located in the main or right pulmonary artery, TEE could clarify the diagnosis within a few minutes without further invasive diagnostic procedures. However, a negative TEE did not exclude left proximal or lobar pulmonary embolism. Received: 28 April 1997 Accepted: 28 November 1997     

Imminent Pulmonary Embolism: A Fatal Mobile Right Atrial Thrombus

Right sided heart thrombi are infrequent and if they are mobile they may cause serious morbidity and mortality due to massive pulmonary embolism or paradoxical embolism. Malignancies are one of the important etiological factors for right heart thrombi. A patient with operated but recurrent ovarian carcinoma, presented with symptoms of heart failure was admitted to oncology department. Rapidly progressing dyspnea and a pre-syncope attack required consultation of a cardiologist and echocardiography revealed a mobile thrombus in the right atrium. Urgent open heart surgery was decided but imminent massive pulmonary embolism complicated the case leading to irreversible cardiogenic shock. By means of the presented case this paper overviews etiological factors and treatment options for right sided heart thrombi.     

Transthoracic echocardiography for suspected pulmonary embolism in the intensive care unit: Unjustly underused or rightfully ignored?

Transthoracic echocardiography (TTE) is an established part of modern medical practice, and its use in documenting cardiac disorders has long been recognized. Since the introduction of 2-dimensional TTE, the right-sided heart chambers have become amenable to fairly accurate analysis, enabling the evaluation of morphologic and functional abnormalities associated with many cardiopulmonary diseases, including pulmonary embolism (PE). The availability of small, portable echocardiographic units combined with an increasing number of intensive care specialists trained in echocardiography makes TTE an attractive modality for the diagnosis of PE in the intensive care unit (ICU). In the ICU setting, prompt decision-making and appropriate triage of critically ill patients can facilitate early institution of therapy for PE while awaiting patient stabilization and further definitive testing. Although several prior reviews incorporate TTE in the overall approach and clinical decision algorithms pertaining to the diagnosis and treatment of pulmonary embolism, no dedicated review exists that focuses purely on TTE. We attempt to fill that gap by reviewing the available literature pertaining to use of TTE in the diagnosis of suspected PE, and by better defining the use of TTE in the ICU setting. Emphasis is placed on the use of TTE as a clinical triage tool for suspected PE.     

Anesthesia and perioperative management for giant adrenal Ewing’s sarcoma with inferior vena cava and right atrium tumor thrombus: A case report

BACKGROUNDEwing’s sarcoma of the adrenal gland with inferior vena cava (IVC) and right atrium thrombus is extremely rare. Here, we report a case of giant adrenal Ewing’s sarcoma with IVC and right atrium tumor thrombus and summarize the anesthesia and perioperative management.CASE SUMMARYA young female was admitted to the Department of Urology with intermittent pain under the right costal arch for four months. Enhanced abdominal computed tomography revealed a large retroperitoneal mass (22 cm in diameter), which may have originated from the right adrenal gland and was closely related to the liver. Transthoracic echocardiography showed a strong echogenic filling measuring 70 mm extended from the IVC into the right atrium and ventricle. After preoperative preparation with cardiopulmonary bypass, sufficient blood products, transesophageal echocardiography and multiple monitoring, tumor and thrombus resection by IVC exploration and right atriotomy were successfully performed by a multidisciplinary team. Intraoperative hemodynamic stability was the major concern of anesthesiologists and the status of tumor thrombus and pulmonary embolism were monitored continuously. During transfer of the patient to the intensive care unit (ICU), cardiac arrest occurred without external stimulus. Cardiopulmonary resuscitation was performed immediately and cardiac function was restored after 1 min. In the ICU, extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) were provided to maintain cardiac, liver and kidney function. Histopathologic examination confirmed the diagnosis of Ewing’s sarcoma. After postoperative treatments and rehabilitation, the patient was discharged from the urology ward.CONCLUSIONAn adrenal Ewing’s sarcoma with IVC and right atrium thrombus is extremely rare, and its anesthesia and perioperative management have not been reported. Thus, this report provides significant insights in the perioperative management of patients with adrenal Ewing’s sarcoma and IVC tumor thrombus. Intraoperative circulation fluctuations and sudden cardiovascular events are the major challenges during surgery. In addition, postoperative treatments including ECMO and CRRT provide essential support in critically ill patients. Moreover, this case report also highlights the importance of multidisciplinary cooperation during treatment of the disease.     

Venous thromboembolic disease presenting as inferior vena cava thrombus extending into the right atrium

With increasing use of echocardiography, especially transesophageal echocardiography, the diagnosis of intracardiac masses has surged. Masses that are most commonly seen in the atrial chambers include thrombi due to atrial fibrillation, cardiac myxomas often located in the atria, and valvular vegetations of infective endocarditis. In this report we present a case of a patient who developed thrombus in the inferior vena cava that extended up to the right atrium and presented as an apparent intracardiac mass. This mass embolized to the right pulmonary artery shortly after diagnosis resulting in pulmonary embolism, which the patient fortunately survived.     

Two cases of complications of the thrombolysis of right heart free-floating thrombi with pulmonary embolism: important role of echocardiographically based management

We present two cases where successful thrombolysis of right heart thrombi and pulmonary embolism was accompanied by serious adverse events. In patient 1 with massive pulmonary thromboembolism, transesophageal ultrasound revealed large right atrial thrombus entrapped in a patent foramen ovale. Initial treatment with heparin was substituted with thrombolysis, which resulted in clinical improvement and dissolution of right heart thrombus but was followed by fatal intracerebral haemorrhage. In patient 2, thrombolysis caused mobilisation of thrombotic mass as evidenced by disappearance of thrombus on ultrasound. Massive pulmonary thromboembolism resulted in circulatory collapse. Short cardiopulmonary resuscitation restored spontaneous circulation and the patient recovered completely.     

Successful thrombolysis of a partially obstructed bileaflet prosthetic heart valve in the mitral position

We describe the case of a woman who presented with dyspnea of abrupt onset and who had recently undergone replacement of the mitral valve with a bileaflet mechanical prosthesis. Transthoracic echocardiographic examination with spectral Doppler recording of transvalvular blood flow revealed a velocity spectrum consistent with obstruction. Transesophageal echocardiography demonstrated partial obstruction of the prosthetic valve due to immobilization of 1 hemidisc in the closed position. This immobilization was apparently caused by a small mass whose appearance was consistent with that of a thrombus. The patient was successfully treated by intravenous administration of a thrombolytic agent. This case demonstrates the value of transesophageal echocardiography in the selection of candidates for thrombolytic treatment in cases of thrombosis of a left-sided valve prosthesis.     

Transesophageal echocardiography in the diagnosis of thrombosis associated with permanent transvenous pacemaker electrodes

OBJECTIVES: We sought to assess the value of transesophageal echocardiography (TEE) in the diagnosis of PM-lead-associated central venous thrombi. BACKGROUND: Venous thrombosis is not infrequent after pacemaker (PM) or implantable cardioverter-defibrillator (ICD) implantation. Previous incidence studies of thrombosis have been based on venography or Doppler ultrasound, but the role of TEE has not been systematically evaluated in this setting. METHODS: Study group comprised 66 consecutive patients (mean age 64 years, 67 % male) referred for implantation of their first PM or ICD and with a successful TEE, transthoracic echocardiography (TTE) and venography at 6 months after implantation. The total number of implanted leads was 110. During the 6 months of clinical follow-up, nuclear ventilation-perfusion scan or spiral computed tomography was performed when symptoms aroused a clinical suspicion of PE. RESULTS: TEE revealed a right atrium (RA) or lower superior vena cava (SVC) thrombus in 6 (9%) patients. These thrombi were not visualized by TTE or venography. Additionally, 12 (20%) patients were found to have venographic subclavian or innominate vein thrombi, but none of those could be diagnosed with TEE. Symptomatic pulmonary embolism (PE) was diagnosed in two and an asymptomatic PE in one individual and two of these occurred among the six patients with a thrombus in TEE. No clinical predictors for thrombosis were found. CONCLUSIONS: TEE is an excellent method to visualize electrodes within the RA and proximal SVC. Electrode-associated RA thrombi appear to be relatively common after PM implantation, and they may remain undetectable by venography or TTE. Although these thrombi are mostly asymptomatic, they can give rise to pulmonary embolism and should also be kept in mind in the differential diagnosis of endocarditis. TEE is the method of choice for the diagnosis of these lesions.