Advertisement

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

  • Nino Mihatov
  • David M. DudzinskiEmail author
Chapter

Abstract

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.

Keywords

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

Supplementary material

325147_1_En_11_MOESM1_ESM.avi (5.2 mb)
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)
325147_1_En_11_MOESM2_ESM.avi (2.6 mb)
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)
325147_1_En_11_MOESM3_ESM.avi (1.2 mb)
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)
325147_1_En_11_MOESM4_ESM.avi (2.6 mb)
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)
325147_1_En_11_MOESM5_ESM.avi (7.5 mb)
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)
325147_1_En_11_MOESM6_ESM.avi (3.1 mb)
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)
325147_1_En_11_MOESM7_ESM.avi (3.3 mb)
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)
325147_1_En_11_MOESM8_ESM.avi (6.2 mb)
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)

References

  1. 1.
    Silverstein MD, et al. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. Arch Intern Med. 1998;158(6):585–93.CrossRefPubMedGoogle Scholar
  2. 2.
    Torbicki A, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2008;29(18):2276–315.CrossRefPubMedGoogle Scholar
  3. 3.
    Torbicki A, ICOPER Study Group, et al. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol. 2003;41(12):2245–51.CrossRefPubMedGoogle Scholar
  4. 4.
    Kabrhel C, et al. Case records of the Massachusetts General Hospital. Case 29-2014. A 60-year-old woman with syncope. N Engl J Med. 2014;371(12):1143–50.CrossRefPubMedGoogle Scholar
  5. 5.
    Douglas PS, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography. J Am Soc Echocardiogr. 2011;24:229–67.CrossRefPubMedGoogle Scholar
  6. 6.
    Agnelli G, Becattini C. Acute pulmonary embolism. N Engl J Med. 2010;363(3):266–74.CrossRefPubMedGoogle Scholar
  7. 7.
    Pruszczyk P, et al. Transoesophageal echocardiography for definitive diagnosis of haemodynamically significant pulmonary embolism. Eur Heart J. 1995;16(4):534–8.PubMedGoogle Scholar
  8. 8.
    Hahn RT, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2013;26:921–64.CrossRefPubMedGoogle Scholar
  9. 9.
    Jaff MR, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension A scientific statement From the American Heart Association. Circulation. 2011;123(16):1788–830.CrossRefPubMedGoogle Scholar
  10. 10.
    Konstantinides S, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J. 2014;35(18):3033–80.PubMedGoogle Scholar
  11. 11.
    Kucher N, et al. Prognostic role of echocardiography among patients with acute pulmonary embolism and a systolic arterial pressure of 90 mm Hg or higher. Arch Intern Med. 2005;165(15):1777–81.CrossRefPubMedGoogle Scholar
  12. 12.
    Sanchez O, et al. Prognostic value of right ventricular dysfunction in patients with haemodynamically stable pulmonary embolism: a systematic review. Eur Heart J. 2008;29(12):1569–77.CrossRefPubMedGoogle Scholar
  13. 13.
    McConnell MV, et al. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996;78(4):469–73.CrossRefPubMedGoogle Scholar
  14. 14.
    Araoz PA, et al. Pulmonary embolism: prognostic CT findings. Radiology. 2007;242(3):889–97.CrossRefPubMedGoogle Scholar
  15. 15.
    Jardin F, Dubourg O, Bourdarias JP. Echocardiographic pattern of acute cor pulmonale. Chest. 1997;111(1):209–17.CrossRefPubMedGoogle Scholar
  16. 16.
    Konstantinides S, et al. Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism. Circulation. 1998;97(19):1946–51.CrossRefPubMedGoogle Scholar
  17. 17.
    Casazza F, et al. Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism. Am J Cardiol. 1997;79(10):1433–5.CrossRefPubMedGoogle Scholar
  18. 18.
    Meyer B, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med. 2014;370(15):1402–11.CrossRefPubMedGoogle Scholar
  19. 19.
    Kuo WT, et al. Catheter-directed therapy for the treatment of massive pulmonary embolism: systematic review and meta-analysis of modern techniques. J Vasc Interv Radiol. 009;20(11):1431–40.Google Scholar
  20. 19A.
    Kuo WT, et al. Pulmonary Embolism Response to Fragmentation, Embolectomy, and Catheter Thrombolysis (PERFECT): initial results from a Prospective Multicenter Registry. Chest. 2015;148(3):667–73.CrossRefPubMedGoogle Scholar
  21. 20.
    Leacche M, et al. Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach. J Thorac Cardiovasc Surg. 2005;129(5):1018–23.CrossRefPubMedGoogle Scholar
  22. 21.
    Goldhaber SZ. Surgical pulmonary embolectomy. Tex Heart Inst J. 2013;40(1):5–8.PubMedPubMedCentralGoogle Scholar
  23. 22.
    Yoo YP, Kang KW. Successful embolectomy of a migrated thrombolytic free-floating massive thrombus resulting in a pulmonary thromboembolism. J Cardiovasc Ultrasound. 2013;21(1):37–9.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 23.
    Kucher N, et al. Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism. Circulation. 2014;129(4):479–86.CrossRefPubMedGoogle Scholar
  25. 24.
    Shammas N, Padaria R, Ahuja G. Ultrasound-assisted lysis using recombinant tissue plasminogen activator and the EKOS EkoSonic endovascular system for treating right atrial thrombus and massive pulmonary embolism: a case study. Phlebography 2015;30:739–43.Google Scholar
  26. 25.
    Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest. 2002;121(3):806–14.CrossRefPubMedGoogle Scholar
  27. 26.
    Donaldson C, et al. Thrombectomy using suction filtration and veno-venous bypass: single center experience with a novel device. Catheter Cardiovasc Interv. 2015;86(2):E81–7.CrossRefPubMedGoogle Scholar
  28. 27.
    Chin AK, et al. Application of a novel venous cannula for en-bloc removal of undesirable intravascular material, Special topics in cardiac surgery (ed. C. Narin) ISBN: 978-953-51-0148-2, InTech, doi:  10.5772/25745. Available from: http://www.intechopen.com/books/special-topics-in-cardiac-surgery/application-of-a-novel-venous-drainage-cannula-for-en-bloc-removal-of-undesirable-intravascular-mate.Google Scholar
  29. 28.
    Mukharji J, Peterson JE. Percutaneous removal of a large mobile right atrial thrombus using a basket retrieval device. Catheter Cardiovasc Interv. 2000;51(4):479–82.CrossRefPubMedGoogle Scholar
  30. 29.
    Beregi JP, et al. Right atrial thrombi: percutaneous mechanical thrombectomy. Cardiovasc Intervent Radiol. 1997;20(2):142–5.CrossRefPubMedGoogle Scholar
  31. 30.
    Momose T, Morita T, Misawa T. Percutaneous treatment of a free-floating thrombus in the right atrium of a patient with pulmonary embolism and acute myocarditis. Cardiovasc Interv Ther. 2013;28(2):188–92.CrossRefPubMedGoogle Scholar
  32. 31.
    Rydman R, et al. Right ventricular function in patients with pulmonary embolism: early and late findings using Doppler tissue imaging. J Am Soc Echocardiogr. 2010;23(5):531–7.CrossRefPubMedGoogle Scholar

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

Personalised recommendations