Rescue thrombolysis partial failure in massive PE complicated with in-transit thrombus

What is it about?

A 58-year-old man who presented with syncope, dyspnea, and hemodynamic compromise was found to have large free-floating right atrial thrombuses on echocardiogram. Decision was made to transfer the patient for emergent atriotomy. Cardiothoracic surgeons declared the patient as inoperable and recommended to use a lytic agent. Alteplase was administered with subsequent near-complete resolution of symptoms and near-normalization of echocardiographic parameters. The post-thrombolytic course was complicated by saddle pulmonary emboli requiring embolectomy. Catheter embolectomy was not available and cardiothoracic surgeon in other center considered the patient to be very high risk for transferring between hospitals and surgical intervention. Ultimately, the critical decision was made, despite the patient having been administered thrombolytic therapy within the previous 48 hours. Alteplase was given, but was not effective and the patient required surgical intervention. Surgical embolectomy was done successfully in another hospital and the patient was discharged with warfarin.

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Why is it important?

The unexpected appearance of an RA thrombus on twodimensional echocardiogram often is a surprise to the clinician. RA thrombus is an uncommon, but life-threatening, a condition that is associated with a high mortality rate. The results of previous studies showed the rate of mortality up to 100% with no treatment and 45% with treatment.2,5 RA thrombus is a challenge for treatment. Yet, there is a dilemma that when the diagnosis of RA thrombus (with or without concomitant PE) has been affirmed, what approach constitutes optimal management. The number of studies in previously treated patients have revealed that the optimal treatment, among patients with no contraindications to thrombolysis, is to use a lytic factor in an effort to dissolve the RA thrombus in situ and successful thrombolysis was associated with an improved survival when compared either with surgery or anticoagulation treatment.

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