engleski

Successful late thrombolysis of right-sided heart thromboembolus in the patient with pulmonary thromboembolism: a case report

The increased use of echocardiography has improved detection of right-sided heart thromboembolism (RHT), particularry in patients with suspected or confirmed pulmonary embolism (PE). These thrombi may become life threatening if they mobilize to the pulmonary circulation. Althgough this is not a new issue, the optimal treatment is not clear. A lack of data also exists to the possibility that old RHT can be successfully thrombolysed. 50-year-old men presented with a sudden onset of chest pain the day before admittance. Physical examination revealed varicous veins and postphlebitic changes on both calves. Perfusion lung scan revealed absent perfusion of the superior lobe of the right lung. TTE and TEE detected a mobile floating serpiginous mass in the right atrium (45x11 mm), prolapsing into the tricuspid valve. Unfractionated heparin (UH) was administered, but without thrombus resolution on the seventh day. The next day phlebography of the lower limbs confirmed the presence of deep venous thrombosis in the right lower extremity. The inferior vena cava filter was deployed and thrombolitic therapy (streptokinase) was administered 24 hours later, followed by intravenous UH infusion and oral warfarin therapy. Control echocardiography showed complete resolution of the RHT. The patient was discharged in good condition, on warfarin, 15 days after the thrombolytic therapy. The real incidence of RHT in PE is unknown. When confirmed by echocardiography, which shoud be performed in every patient with suspected PE, urgent removal of thrombus is mandatory. A large retrospective analysis reported an overall mortality rate of 27.1%. The mortality rate associated with untreated causes, anticaogulant therapy, surgical embolectomy and thrombolysis were 100%, 28.6%, 23.8% and 11.3%, respectively. According to the same study thrombolytic therapy was associated with a significant reduction in mortality (p<0.05), when compared to anticoagulant or surgical therapy. In our patient, the initial treatment with UH was unsuccessful. Therefore, we decided to insert inferior vena cava filter and administer thrombolytic therapy. The result was complete resolution of RHT, demonstrating that not only fresh thromboemboli are prone to thrombolysis, and that even late thrombolytic therapy could be a very effective treatment in such causes.

thrombolytic therapy; venous thrombosis; thromboembolism; pulmonary embolism

nije evidentirano