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Due to the low initial deficit and the progressive improvement of the clinical picture&#44; fibrinolysis was rejected&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">During his stay in the emergency department&#44; the patient developed epigastric pain&#46; An electrocardiogram was performed showing negative T waves in DI to DII&#44; in aVF and V1&#8211;V6&#46; Serial troponin T determinations rose from 38 to 570<span class="elsevierStyleHsp" style=""></span>ng&#47;L&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Acute coronary syndrome was suspected&#44; so a transthoracic echocardiogram was performed&#44; which revealed an image consistent with very long&#44; mobile thrombi in both the left atrium and the right atrium each measuring approximately 4<span class="elsevierStyleHsp" style=""></span>cm&#44; that appeared to cross continuously through a patent foramen ovale&#44; suggestive of thrombus in transit &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Findings consistent with severe pulmonary hypertension and severe right ventricular dilatation and dysfunction were also observed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">To confirm the presence of thrombus in transit&#44; the study was completed with a transesophageal echocardiogram&#44; and a chest CT was requested in which acute pulmonary thromboembolism &#40;PTE&#41; was identified with bilateral involvement from the main branches&#44; along with data suggestive of pulmonary hypertension and right cavity overload&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Given these findings&#44; the patient was admitted to an intensive care unit for monitoring and treatment&#44; despite being hemodynamically stable since his admission to the emergency room&#46; The cardiac surgery department of the reference center was contacted&#44; and surgery was ruled out in view of the high surgical risk presented by the patient&#46; Conservative treatment with low molecular weight heparin was adopted and the patient was subsequently transferred to the pulmonology department&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">During his stay on the ward&#44; the patient remained clinically and hemodynamically stable at all times&#46; A follow-up echocardiogram showed a significant decrease in thrombus size and right cavity involvement&#44; so he was discharged after a hospital stay of 16 days&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">After 1 month of follow-up by the dedicated pulmonary circulation clinic&#44; he showed good progress&#44; and an echocardiogram confirmed the disappearance of the atrial thrombus and normalization of the morphology and function of the right cavities&#46; Oral anticoagulation with vitamin K was initiated with good tolerance and regular follow-up was continued&#46; One year after the episode&#44; he was continuing to receive indefinite anticoagulation&#44; free of complications and with recovery of his baseline situation&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The treatment of choice of right cavity thrombus is not well defined&#46; Therapeutic alternatives include anticoagulation&#44; catheter-guided or systemic thrombolysis&#44; and surgical embolectomy&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The European Society of Cardiology suggests the use of thrombolytics in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> However&#44; to date&#44; no clinical trials have demonstrated the efficacy of this treatment&#44; and the only scientific evidence that exists are clinical case series and meta-analyses of these series&#44; and results of registries focused mainly on pulmonary embolism&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The first meta-analysis published by Kinney et al&#46; in 1989&#44; which included 199 patients with right-cavity thrombus&#44; proposed anticoagulation as a first option&#44; as they observed lower mortality in patients receiving anticoagulant therapy compared with those treated with thrombolysis and embolectomy &#40;30&#37; vs 38&#37; vs 38&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> However&#44; in the same year&#44; the European Cooperative Study led by the European Echocardiography Working Group was conducted in the same number of patients&#44; and found that patients who received anticoagulation showed higher mortality in the short term than those treated with thrombolysis or embolectomy &#40;64&#37; vs 40&#37; vs 27&#37;&#41;&#44; so the authors suggested surgery as a more effective treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Years later&#44; Rose et al&#46; positioned themselves in favor of thrombolytic treatment after a retrospective analysis of 177 patients between 1966 and 2000 in which they observed that both anticoagulation and embolectomy showed a worse prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> In 2003&#44; Torbicki et al&#46; reported on a small cohort of 42 patients from the International Cooperative Pulmonary Embolism Register &#40;ICOOPER&#41;&#44; in whom they found a similar therapeutic response among all therapeutic options&#44; with a mortality rate of 23&#46;5&#37; in anticoagulated patients&#44; 20&#46;8&#37; in thrombolysed patients&#44; and 25&#37; in surgically operated patients&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Subsequently&#44; in 2015&#44; a study by Athappan et al&#46; was published&#44; which also favored thrombolysis due to the increased survival compared to anticoagulation&#46; However&#44; there were no statistically significant differences between embolectomy and anticoagulant therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The management of the case discussed here was based on a recent study published in 2017 by Barrios et al&#46;&#44; designed from the RIETE &#40;<span class="elsevierStyleItalic">Computerized Registry of Patients with Thromboembolic Disease</span>&#41;&#44; which included 325 patients with PTE and thrombi in the right cavities&#46; There were no differences between reperfusion therapy and anticoagulation in terms of short-term survival and the presence of major bleeding&#46; Reperfusion therapy was also associated with an increased risk of recurrence of venous thromboembolism&#46; Therefore&#44; they concluded that anticoagulation therapy was appropriate for most patients with co-existing PTE and right-cavity thrombus&#44; and reperfusion therapy should be reserved for patients with PTE and shock or hypotension&#44; regardless of the presence of thrombi in right cavities&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">However&#44; in the light of the existing data&#44; the debate on the treatment of choice of these patients remains open&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interests</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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Scientific Letter
Thrombus in Transit
Trombo en tránsito
Leyre Chascoa,
Corresponding author
leyrech10@gmail.com

Corresponding author.
, Aitor Ballaza, Mikel Aingeru Oribea, Amaia Artaraza, Amaia Aramburua, Sonia Velascob, José Juan Onaindiab, Cristóbal Estebana
a Servicio Neumología, Hospital Galdakao-Usansolo, Galdakao, Vizcaya, Spain
b Servicio Cardiología, Hospital Galdakao-Usansolo, Galdakao, Vizcaya, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Thrombi in right cardiac cavities&#44; described in less than 4&#37; of patients with pulmonary embolism&#44; are rare and in most cases confer a poor prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a> Nevertheless&#44; there is no consensus on the treatment of choice in these patients&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 72-year-old man&#44; former smoker&#44; diagnosed with severe COPD&#44; Parkinson&#39;s disease and Pick&#39;s disease&#44; who consulted the emergency department for a sudden onset of loss of strength and sensitivity in the right side of the face and right hand&#44; along with dysarthria&#46; The stroke code was activated&#44; and a perfusion computed tomography &#40;CT&#41; was performed which revealed early signs of acute infarction in the left middle cerebral artery&#46; Due to the low initial deficit and the progressive improvement of the clinical picture&#44; fibrinolysis was rejected&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">During his stay in the emergency department&#44; the patient developed epigastric pain&#46; An electrocardiogram was performed showing negative T waves in DI to DII&#44; in aVF and V1&#8211;V6&#46; Serial troponin T determinations rose from 38 to 570<span class="elsevierStyleHsp" style=""></span>ng&#47;L&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Acute coronary syndrome was suspected&#44; so a transthoracic echocardiogram was performed&#44; which revealed an image consistent with very long&#44; mobile thrombi in both the left atrium and the right atrium each measuring approximately 4<span class="elsevierStyleHsp" style=""></span>cm&#44; that appeared to cross continuously through a patent foramen ovale&#44; suggestive of thrombus in transit &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Findings consistent with severe pulmonary hypertension and severe right ventricular dilatation and dysfunction were also observed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">To confirm the presence of thrombus in transit&#44; the study was completed with a transesophageal echocardiogram&#44; and a chest CT was requested in which acute pulmonary thromboembolism &#40;PTE&#41; was identified with bilateral involvement from the main branches&#44; along with data suggestive of pulmonary hypertension and right cavity overload&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Given these findings&#44; the patient was admitted to an intensive care unit for monitoring and treatment&#44; despite being hemodynamically stable since his admission to the emergency room&#46; The cardiac surgery department of the reference center was contacted&#44; and surgery was ruled out in view of the high surgical risk presented by the patient&#46; Conservative treatment with low molecular weight heparin was adopted and the patient was subsequently transferred to the pulmonology department&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">During his stay on the ward&#44; the patient remained clinically and hemodynamically stable at all times&#46; A follow-up echocardiogram showed a significant decrease in thrombus size and right cavity involvement&#44; so he was discharged after a hospital stay of 16 days&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">After 1 month of follow-up by the dedicated pulmonary circulation clinic&#44; he showed good progress&#44; and an echocardiogram confirmed the disappearance of the atrial thrombus and normalization of the morphology and function of the right cavities&#46; Oral anticoagulation with vitamin K was initiated with good tolerance and regular follow-up was continued&#46; One year after the episode&#44; he was continuing to receive indefinite anticoagulation&#44; free of complications and with recovery of his baseline situation&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The treatment of choice of right cavity thrombus is not well defined&#46; Therapeutic alternatives include anticoagulation&#44; catheter-guided or systemic thrombolysis&#44; and surgical embolectomy&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The European Society of Cardiology suggests the use of thrombolytics in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> However&#44; to date&#44; no clinical trials have demonstrated the efficacy of this treatment&#44; and the only scientific evidence that exists are clinical case series and meta-analyses of these series&#44; and results of registries focused mainly on pulmonary embolism&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The first meta-analysis published by Kinney et al&#46; in 1989&#44; which included 199 patients with right-cavity thrombus&#44; proposed anticoagulation as a first option&#44; as they observed lower mortality in patients receiving anticoagulant therapy compared with those treated with thrombolysis and embolectomy &#40;30&#37; vs 38&#37; vs 38&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> However&#44; in the same year&#44; the European Cooperative Study led by the European Echocardiography Working Group was conducted in the same number of patients&#44; and found that patients who received anticoagulation showed higher mortality in the short term than those treated with thrombolysis or embolectomy &#40;64&#37; vs 40&#37; vs 27&#37;&#41;&#44; so the authors suggested surgery as a more effective treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Years later&#44; Rose et al&#46; positioned themselves in favor of thrombolytic treatment after a retrospective analysis of 177 patients between 1966 and 2000 in which they observed that both anticoagulation and embolectomy showed a worse prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> In 2003&#44; Torbicki et al&#46; reported on a small cohort of 42 patients from the International Cooperative Pulmonary Embolism Register &#40;ICOOPER&#41;&#44; in whom they found a similar therapeutic response among all therapeutic options&#44; with a mortality rate of 23&#46;5&#37; in anticoagulated patients&#44; 20&#46;8&#37; in thrombolysed patients&#44; and 25&#37; in surgically operated patients&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Subsequently&#44; in 2015&#44; a study by Athappan et al&#46; was published&#44; which also favored thrombolysis due to the increased survival compared to anticoagulation&#46; However&#44; there were no statistically significant differences between embolectomy and anticoagulant therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The management of the case discussed here was based on a recent study published in 2017 by Barrios et al&#46;&#44; designed from the RIETE &#40;<span class="elsevierStyleItalic">Computerized Registry of Patients with Thromboembolic Disease</span>&#41;&#44; which included 325 patients with PTE and thrombi in the right cavities&#46; There were no differences between reperfusion therapy and anticoagulation in terms of short-term survival and the presence of major bleeding&#46; Reperfusion therapy was also associated with an increased risk of recurrence of venous thromboembolism&#46; Therefore&#44; they concluded that anticoagulation therapy was appropriate for most patients with co-existing PTE and right-cavity thrombus&#44; and reperfusion therapy should be reserved for patients with PTE and shock or hypotension&#44; regardless of the presence of thrombi in right cavities&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">However&#44; in the light of the existing data&#44; the debate on the treatment of choice of these patients remains open&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interests</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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ISSN: 15792129
Original language: English
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