MOBILE RIGHT HEART THROMBI AND PULMONARY- EMBOLISM - DIAGNOSTIC AND THERAPEUTIC PROBLEMS IN 12 CASES

The objectives of this report were to analyse clinical presentation, e chocardiographic features and diagnostic and therapeutic problems pose d by an unusual form of thrombo-embolic disease mobile right heart thr ombosis. Systematic echocardiography in 170 cases of severe pulmonary embolism identified mobile right thrombi in 12 cases. The auscultatory findings were abnormal in 6 cases, 3 showing signs of tricuspid obstr uction. Two-dimensional echocardiography showed an extremely mobile ri ght atrial mass, sometimes prolapsing across the tricuspid valve, whic h was variously spheric, ovoid or wormlike ; dilatation of the right h eart chambers and echocardiographic signs of cor pulmonale were observ ed in all cases. The differential diagnosis with other embolic masses of the right atrium and, above all, with well-developed Chiari network s, may be difficult and requires transoesophageal echocardiography. Pu lmonary angiography is contra-indicated because of the risk of embolis m. Embolectomy under cardiopulmonary bypass was carried out in 8 patie nts, immediately after echocardiography in 6 cases. The thrombus was r ecovered from the right atrium in 6 cases and from the pulmonary arter y in 2 cases : there was one operative death. Medical treatment was ad ministered to 3 inoperable patients. The clinical and echocardiographi c outcome was good in 2 of these but the third patient died ; autopsy revealed thrombi in the right atrium and pulmonary artery. One patient died before any treatment could be given and autopsy showed the throm bus in the pulmonary artery. These results confirm the extreme instabi lity of this type of thrombus and the risk of death due to its embolis m. Mobile right heart thrombi is a particularly serious form of thromb oembolic disease as the mass may embolise at any time and cause severe pulmonary embolism. The diagnosis requires systematic echocardiograph y whenever acute pulmonary embolism is suspected. It is a medico-surgi cal emergency, the treatment of choice seeming to be embolectomy under cardiopulmonary bypass whenever possible.