Right sided cardiac thrombi can result in pulmonary embolus leading to hemodynamic instability, arrest and mortality even in spite of anticoagulation. We present a case of successful TEE guided removal of a right atrial clot using an Angiovac aspiration device from a patient with high surgical risk for open removal.
A 52 year old male with a history of Protein S deficiency, multiple DVTs, pulmonary embolus on lifelong Coumadin, obesity with severe OSA, HIV with undetectable viral loads, chronic kidney disease with a baseline Creatinine of 2.7, presented with acute shortness of breath and chest pain. On arrival to the emergency department, he had an episode of syncope and was noted to be cyanotic and in Atrial Fibrillation with rapid ventricular rate. Bedside TTE revealed a severely dilated right ventricle, with decreased RV function, and a flattened RV septum during both systole and diastole. Additionally, a mobile mass was noted in the right atrium. Estimated PASP based on the TR jet was 70 mmHg. Based on these findings a V/Q scan was performed (CT contraindicated due to elevated Creatinine) which showed high probability for PE. The patient was subsequently started on a heparin infusion and brought to the operating room for percutaneous embolectomy (Angiovac).
After placing an awake arterial line and central venous access, the patient was induced and placed under general anesthesia. Intraoperative TEE revealed a large, mobile, thrombus in the right atrium intermittently advancing across the tricuspid valve. Real-time TEE and fluoroscopy helped guide successful clot extraction using the Angiovac system. Post-procedural TEE revealed no residual clot. The patient was successfully extubated and brought to the critical care unit for monitoring.
While conventional therapy and open intervention have historically been primary treatment options for pulmonary embolisms and intradcardiac masses, both have inherent risks including increased bleeding, distal embolization of thrombi and intra-op morbidity/mortality. While the Angiovac Thrombectomy system is relatively conventional, prior studies have illustrated successful removal of right atrial thrombi in 73% of cases with 87% survival to the end of hospitalization (1). While fluoroscopy guides the Angiovac to the thrombus location, TEE allows for direct real time vision of clot extraction, examination for residual mass and right heart strain, and monitoring for Angiovac complications including right atrial/ventricular rupture and tamponade. The less invasive percutaneous aspiration by AngioVac has been proven to be successful with a higher safety profile when used with TEE and fluoroscopy guidance.
