CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 4, July/August 2011
206
AFRICA
Conclusion
Dynamic LVOT obstruction may be encountered as a severe
complication during acute coronary syndromes. In the case of
extensive anterior ischaemia, even if mechanical reperfusion is
performed, a Doppler echocardiogram should be obtained for
the outflow tract velocity if the clinical status is deteriorating or
not improving. If Doppler investigation determines the presence
of a dynamic LVOT obstruction, the beta-blocker esmolol can
be used.
References
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García Quintana A, Ortega Trujillo JR, Padrón Mújica A,
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Cardiogenic shock due to dynamic left ventricular outflow tract
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2.
Bartunek J, Vanderheyden M, de Bruyne B. Dynamic left ventricu-
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potential mechanism of myocardial rupture.
Eur Heart J
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Hrovatin E, Piazza R, Pavan D,
et al.
Dynamic left ventricular outflow
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Echocardiography
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Haley JH, Sinak LJ, Tajik AJ,
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Snake-like thrombus in the right atrium causing
pulmonary embolism
CY KARABAY, G KOCABAY, A KALAYCİ, R ZEHİR, M MERT, C KİRMA
Abstract
In this report, we present a case of an 84-year-old woman
treated with a low-dose prolonged infusion of tissue plas-
minogen activator (tPA) for a free-floating thrombus in the
right atrium.
Keywords:
thrombus, thrombolysis, echocardiography
Submitted 9/7/10, accepted 29/7/10
Published online: 10/12/10
Cardiovasc J Afr
2010;
22
: 206–207
DOI: 10.5830/CVJA–2010–060
Free-floating right-heart thrombi can be seen in four to 18% of
patients presenting with acute pulmonary embolism.
1
Most are
found in the right atrium and half have a mobile worm- or snake-
like structure.
2
Although right atrial thrombo-embolism is rare, it
should be considered a cardiological emergency that could cause
death by massive pulmonary or paradoxical embolism.
3
The
presence of a right-heart thrombus increases the risk of mortal-
Kartal Kosuyolu Yuksek Ihtisas Heart Education and
Research Hospital, Department of Cardiology, Istanbul,
Turkey
CY KARABAY, MD
G KOCABAY, MD,
A KALAYCİ, MD
R ZEHİR, MD
C KİRMA, MD
Kayseri Educational and Research Hospital, Department of
Endocrinology and Metabolism, Kayseri, Turkey
M MERT, MD
ity compared to the presence of a pulmonary thrombo-embolus
alone. Despite this, the optimal management of right-heart
thrombo-emboli remains unclear.
4
Case report
An 84-year-old woman with chronic obstructive lung disease and
chronic atrial fibrillation was admitted to our hospital for new-
onset dyspnoea and palpitations. On physical examination, she
had an irregular pulse of 110 beats/min and her blood pressure
was 120/75 mmHg. She was dyspnoeic with a respiratory rate
of 25 breaths per minute. Her temperature was 36.5°C. She had
normal heart sounds except for a 3/6 pansystolic murmur in the
tricuspid area, and her lung fields were clear. There was clinical
evidence such as swelling and pain, indicating right deep-venous
thrombosis.
The electrocardiogram showed atrial fibrillation. The plasma
D-dimer level was
>
5 000 ng/ml (normal
<
500 ng/ml) and the
BNP level was 990 ng/ml (normal
<
150 ng/ml). Arterial blood
gas measurement drawn in room air showed oxygen saturation of
92%, pH 7.40, partial pressure of carbon dioxide 35 mmHg and
of oxygen 60 mmHg. A Doppler ultrasonography revealed right
femoral deep-vein thrombosis.
We performed transthoracic echocardiography, which showed
enlargement of the right atrium and a snake-like mobile mass,
moving during systole and diastole into the right ventricle and
atrium. The main pulmonary artery and its branches were clear.
Doppler examination showed moderate tricuspid regurgitation
and pulmonary artery hypertension (pulmonary artery systolic
pressure of 50 mmHg) (Fig. 1).
The laboratory findings and her clinical situation were consist-
ent with a diagnosis of acute pulmonary embolism. Although she
was not hypotensive, and transthoracic echocardiography did not
