Right atrial thrombi, the management conundrum: 2 case reports

Abstract

Objective: Background: Case Reports: Conclusions: Unusual clinical course There are no guidelines providing an algorithmic approach for the management of right atrial thrombi, to date, owing to a lack of strong supporting studies. In this case series, we describe 2 cases of high-risk patients with massive right atrial thrombi who had different outcomes. Case 1: A 62-year-old man with ischemic cardiomyopathy and atrial fibrillation, who was on a permanent pace-maker for sick sinus syndrome and was noncompliant with medication for 2 years, presented to the Emergency Department for evaluation of a 2-month history of progressive shortness of breath and swollen neck veins. A cardiac ultrasound confirmed a large right atrial thrombus, and a computed tomography (CT) pulmonary angiogram was negative for pulmonary emboli. He was managed with a heparin infusion and thrombolytic therapy with favorable evolution. Case 2: A 66-year-old man, with a past medical history of nonischemic cardiomyopathy, atrial fibrillation, deep venous thrombosis, and pulmonary emboli a year earlier, presented to an urgent care unit with sudden onset of shortness of breath. A cardiac ultrasound confirmed a large right atrial thrombus, and a CT pulmonary an-giogram confirmed bilateral pulmonary emboli. He was managed with a heparin infusion and EkoSonic endo-vascular system therapy. He subsequently needed venoarterial extracorporeal membrane oxygenation for car-diopulmonary resuscitation and underwent mechanical aspiration thrombectomy. The patient’s evolution was unfavorable. In the absence of an evidence-based guideline to approach right atrial thrombi, management should be indi-vidualized for each patient, based on the type of thrombi, hemodynamic status, and presence or absence of associated pulmonary emboli.