Echocardiographic Guidance for Catheter-Based Removal of Right-Sided Intracardiac Thrombus

  • Nino Mihatov
  • David M. DudzinskiEmail author


Pulmonary embolus and clot-in-transit represent medical emergencies that, depending in part on hemodynamic compromise and imaging findings, may require invasive percutaneous therapies. Echocardiography provides immediate noninvasive bedside information to diagnose these conditions and risk stratify these patients. Percutaneous treatment modalities are then guided by real-time transesophageal echocardiography. Procedural echocardiographers must be knowledgeable of the differential diagnosis of intracardiac masses, familiar with use of three-dimensional imaging, and aware of relevant transesophageal echocardiographic anatomy that will help the interventionalist guide their therapeutic devices within the confines of the beating heart as well as confirm complete extraction of intracardiac masses.


Pulmonary embolism Clot-in-transit Intracardiac thrombi Right heart Right ventricle transthoracic echocardiography Transesophageal echocardiography Suction thrombectomy 

Supplementary material

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Movie 11.1 Clot-in-transit in the right atrium. A clot-in-transit is visualized in right atrium in the modified bicaval TEE view. Because the clot exists in three-dimensions, moves in- and out- of the plane of the TEE image, and changes shape during the cardiac cycle, there may appear to be multiple distinct, independent lobes. However, the clot is characterized by a lengthy overall “worm”-like or serpiginous shape, as can be confirmed by 3D TEE. Venous clots typically have a relatively homogenous echotexture as is demonstrated (AVI 5328 kb)
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Movie 11.2 3D TEE of clot-in-transit in the right atrium. The clot-in-transit seen in Movie 11.1 is now visualized by 3D TEE, and the contiguous serpiginous nature of the single venous clot is apparent (AVI 2654 kb)
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Movie 11.3 Clot-in-transit in the right ventricle outflow tract. A clot-in-transit is visualized in the right ventricle and proximal pulmonary artery on a TEE short axis view. The shape of the clot changes with the motion of the cardiac cycle (AVI 1212 kb)
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Movie 11.4 Catheter-associated thrombi. A mobile thrombus, attached to a superior vena cava catheter, is visualized in the TEE bicaval view (AVI 2669 kb)
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Movie 11.5 Clot at the Eustachian valve. The Eustachian valve is visible by inserting the probe more distally when compared to a typical mid-esophageal four chamber view, and then rotating the probe to follow the right atrium toward the inferior vena cava. The Eustachian valve is one location where intracardiac masses entering the heart from the inferior vena cava may be “caught” or appear to be attached (AVI 7692 kb)
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Movie 11.6 TEE guidance of large bore suction thrombectomy device. Real-time TEE is employed, along with fluoroscopy, to guide catheters and aspiration devices in the heart. In this movie, the large bore aspiration catheter enters the right atrium from the inferior vena cava, and is ultimately directed toward the superior vena cava (AVI 3187 kb)
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Movie 11.7 Large bore aspiration of material from the right atrium. The large bore suction catheter aspirates intracardiac material from the right atrium (AVI 3354 kb)
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Movie 11.8 Echocardiographic search for residual material after aspiration thrombectomy. During and after aspiration thrombectomy of a clot-in-transit, detailed echocardiographic views of right sided structures are indicated to assess for any residual clot burden. In this mid-esophageal short axis right ventricle inflow view, an independently mobile echodensity on the sub-tricuspid valve apparatus was visualized only after modifying the view by adding extra rotation on the probe. Such findings may indicate debris caught among ventricular trabeculations or valvular chordae (AVI 6386 kb)


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Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of MedicineMassachusetts General HospitalBostonUSA
  2. 2.Divisions of Cardiology, Echocardiography, and Critical CareMassachusetts General HospitalBostonUSA
  3. 3.Division of Pulmonary/Critical Care, and Cardiac Ultrasonography LaboratoryMassachusetts General HospitalBostonUSA

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