Swinging in the RV


Today we begin a new category on our blog. Caught My Eyes. The idea is simple: we want to share with you, hopefully weekly, some of the more interesting, intriguing, peculiar, and unusual images we came across in our daily practice. From point-of-care ultrasound to CT images, and everything in between. Add some bad jokes and maybe some personal insults, and that’s it! But of course, always preserving our patients’ identity and integrity.

A 26-year-old woman, with history of colon cancer, presents with subtle shortness of breath and tachycardia in our emergency department. Due to her cancer history, a CTPA was ordered, and a segmental pulmonary embolism was diagnosed. The ED guys started enoxaparin, and although she was hemodynamically stable, she was admitted to our ICU for the night.

We don’t have a policy that every patient gets a point-of-care echo at admission, in my shifts, most of the time I do it. Anyhow, since I had a resident with me and nothing better to do… Echo it is.

The first image we acquired was this parasternal long axis view (PSLA):

 

I won’t spend time with normal findings. But one thing caught my eyes. An echodense image was popping up in the right ventricle outflow tract (RVOT). Well, that’s interesting. We did what you always should do when some unexpected finding appears when performing an echo. Get more views!

Parasternal short axis at the aortic valve level

 

Beautiful! I love the PSSA Ao valve level view. You can see both atria, tricuspid valve, RVOT, pulmonary valve, aortic valve, the interatrial septum. Definitely, there’s this mobile, echodense structure, which appears to be attached to the tricuspid valve, swinging between the RA and RV. Is that a thrombus? Yeah, it is. Oh, this was a first timer. Also, we got another view:

 

This was supposed to be an RV inflow view (from the PSLA view, you tilt the transducer inferomedially), but we ended up seeing more from the left heart than we ought to and less from the RA. However, that’s another view showing the thrombus swinging between RV and RA.

Were we concerned? Yeah, a bit. What if it detached and went straight to her pulmonary artery? Fortunately, she was stable and nothing happened. We stuck with our treatment and enoxaparin did its job.

In patients with PE, right heart thrombi are quite uncommon, going from 3.6% to 23.6%. The major etiologies are: embolic (due to DVT) or in situ (arrhythmia, catheters, pacemaker wires or stagnant blood) [1]. Although we couldn’t find any signs of DVT, and since our patient didn’t have any catheter, it was safe to assume that due to her cancer history the probable etiology was from an embolic event.

I didn’t know, but there is a classification of right heart thrombus in 3 categories, based on its morphology[2]:

-Type A: Long, thin, extremely mobile thrombi which resembled a worm or a snake. Associated with DVT.

-Type B:  Immobile, non-specific clots resembling left heart thrombi. Associated with cardiac abnormalities.

-Type C: Not worm-shaped but highly mobile. Has aspects of both A and B.

Why is this important? Well, maybe as a prognostic tool. Patients with type A thrombus have higher PE incidence (98%) and thrombus related mortality (42%), while the PE incidence was 45% in type B and 62% in type C, and thrombus related mortality was 4% in type B and 14% in type C.

Ok, most of the time our post will be shorter than this one, but since the subject was fascinating and I could find some literature about it, I think it worth the typing.

 

1- Jammal M, Milano P, Cardenas R, Mailhot T, Mandavia D, Perera P. The diagnosis of right heart thrombus by focused cardiac ultrasound in a critically ill patient in compensated shock Crit Ultrasound J. 2015; 7(1).
2- The European Cooperative Study on the clinical significance of right heart thrombi. European Working Group on Echocardiography. European heart journal. 1989; 10(12):1046-59.


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Swinging in the RV

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