MANAGEMENT OF MOBILE RIGHT ATRIAL THROMBI - A THERAPEUTIC DILEMMA

Background: Mobile right atrial thrombus is an uncommon finding on two -dimensional (2D) echocardiography. Therapeutic alternatives include s ystemic heparinization, systemic or local thrombolysis, and surgical r emoval. We report our clinical experience in six patients over a 3-yea r period (6000 echocardiograms) at a tertiary care referral center. Me thods: There were four men and two women with a mean age of 63 years ( range: 47 to 73 years). Indications for echocardiography consisted of progressive dyspnea and chest pain in five patients and syncope with c hest pain in one patient. Results: All were observed to have a mobile thrombus in the right atrium. Ventilation perfusion (V/Q) scanning con firmed V/Q mismatch in all patients. Subsequent echocardiography (minu tes to 1 day later) in three patients demonstrated absence of the thro mbus suggesting pulmonary embolization. One patient died during transe sophageal echocardiography (TEE) and autopsy confirmed a large pulmona ry embolization in the main pulmonary artery. Treatment consisted of h eparinization in 3 patients, systemic thrombolysis in 1 patient, and s urgical removal of the thrombus in 1 patient. At surgery, a long serpi ginous thrombus was seen in the right atrium, tethered to a fenestrate d eustachian valve. There were 3 deaths: 1 patient treated with hepari n; 1 patient treated with thrombolysis; and 1 during TEE. Two of the t hree patients treated with heparin and one patient undergoing surgical removal survived hospitalization. Conclusions: Mobile thrombus in the right atrium is an unusual echocardiographic finding. It portends a p oor prognosis with death due to pulmonary embolism.