Introduction: Treatment of right ventricular (RV) thrombus in the setting of pulmonary embolism (PE) can be challenging as optimal management is not well-established. We present a case of RV thrombus in the setting of acute PE treated with anticoagulation and thrombectomy complicated by clot migration into the pulmonary vasculature.
Description: A 55-year-old male with a history of bronchiectasis presented to the hospital with 2 weeks of dyspnea and bilateral lower extremity swelling. He was hypoxemic on arrival requiring 4L supplemental oxygen. He was hemodynamically stable and afebrile. Physical exam was remarkable for wheezing and trace bilateral edema. His BNP was > 1000 pg/ml. Electrocardiogram showed normal sinus rhythm with a right bundle branch block. Bilateral lower extremity ultrasound was negative for deep vein thrombosis. Computed tomography angiogram (CTA) of the chest showed small distal segmental and subsegmental PE in the left lower lobe and extensive cystic lung disease. Transthoracic echocardiogram (TTE) demonstrated a moderately dilated RV with a large, spherical, mobile thrombus located along the interventricular septum, and severely decreased RV function. He was placed on a heparin infusion. His simplified pulmonary embolism severity index score was 3 due to relative hypotension without overt shock, placing him in the intermediate-high risk PE category. Decision was made to hold off on ½ dose tPA and to pursue emergent aspiration thrombectomy. During the procedure, only a small amount of clot was retrieved. Bilateral pulmonary arteriograms performed in the IR suite were unremarkable. Repeat TTE with contrast showed improvement in RV function without evidence of clot. Repeat CTA demonstrated new segmental and subsegmental PEs in the right lower lobe consistent with clot migration status post thrombectomy. He remained stable throughout his admission. The patient was transitioned to direct oral anticoagulant therapy and was discharged from the hospital on 2L supplemental oxygen.
Discussion: Right heart thrombi occur in about 4% of PE cases and are associated with significant morbidity and mortality. Aspiration thrombectomy of RV thrombus can cause clot migration into the pulmonary veins. More research is needed to establish treatment guidelines for RV thrombus.
