Anjo, D.

Antunes, N.

Cyrne-Carvalho, H.

Silva-Vieira, M.

Torres, S.

Repositório Científico do Centro Hospitalar do Porto

Document downRev Port Cardiol. 2013;32(1):71--72Revista Portuguesa deCardiologiaPortuguese Journal of Cardiologywww.revportcardiol.orgIMAGES IN CARDIOLOGYPulmonary  embolism  with  thromboembolus  in transitEmbolia  pulmonar  com  trombo-êmbolo  em  trânsitoMiguel Silva Vieira ∗, Diana Anjo, Nuno Antunes, Henrique Carvalho, Severo TorresCardiology  Department,  Hospital  Santo  António  -- Centro  Hospitalar  do  Porto,  Porto,  PortugalReceived  10  June  2012;  accepted  2  July  2012loaded from http://www.elsevier.pt, day 04/11/2014. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.Available  online  14  December  2012PwthucftbifEPdaCfAn  88-year-old  woman  was  admitted  with  syncope  andrapidly  evolved  with  shock.  Her  medical  history  wasnotable  for  recent  orthopedic  surgery.  The  electrocardio-gram  showed  ST-segment  depression  in  the  precordial  andinferior  leads  (Figure  1).  Rapid  troponin  I  assay  was  pos-itive.  Bedside  echocardiography  revealed  a  dilated  anddysfunctional  right  ventricle,  with  akinesia  of  the  lat-eral  wall  and  paradoxical  interventricular  septal  motion(Figure  2A).  Remarkably,  a  large,  worm-like,  mobile,  free-ﬂoating  right  atrial  mass  was  noted,  insinuating  throughthe  tricuspid  valve  during  systole  (Figure  2B--D).  Acute  pul-monary  embolism  (PE)  with  right  heart  thromboemboluswas  strongly  suspected,  so  prompt  resuscitation  and  anti-coagulant  therapy  were  started,  while  emergency  thoraciccomputed  tomography  angiography  conﬁrmed  bilateral  cen-tral  emboli  (Figure  3A--C).  Despite  the  high  bleeding  risk,thrombolysis  was  undertaken,  given  the  life-threateningcondition,  with  gradual  improvement  in  clinical  statusand  no  major  bleeding  complications.  No  right  heartthromboembolus  was  found  in  the  follow-up  echocar-diogram  and  the  patient  had  an  uneventful  hospitalcourse.Right  heart  thromboemboli  in  transit  are  an  inciden-tal  ﬁnding  in  up  to  20%  of  patients  with  acute  high-risk∗ Corresponding author.E-mail address: zemiguelvieira@gmail.com (M. Silva Vieira).tsiRo0870-2551/$  –  see  front  matter  ©  2012  Sociedade  Portuguesa  de  Cardiologhttp://dx.doi.org/10.1016/j.repc.2012.07.008E,  and  are  associated  with  hemodynamic  compromise  andorse  prognosis,  especially  with  mobile,  worm-like  type  Ahromboembolus.  Bedside  echocardiography  is  particularlyelpful  in  making  a  rapid  presumptive  diagnosis,  avoidingnnecessary  delay  in  treatment.  Their  management  remainsontroversial,  with  concerns  of  bleeding  complications,ragmentation  and  new  embolization  with  readily  availablehrombolytic  therapy.  Even  so,  their  natural  history  shoulde  borne  in  mind  when  evaluating  bleeding  risk,  particularlyn  elderly  patients,  whose  perceived  risk  could  exclude  themrom  a potentially  life-saving  therapy.thical disclosuresrotection  of  human  and  animal  subjects.  The  authorseclare  that  no  experiments  were  performed  on  humans  ornimals  for  this  investigation.onﬁdentiality  of  data.  The  authors  declare  that  they  haveollowed  the  protocols  of  their  work  center  on  the  publica-ion  of  patient  data  and  that  all  the  patients  included  in  thetudy  received  sufﬁcient  information  and  gave  their  writtennformed  consent  to  participate  in  the  study.ight  to  privacy  and  informed  consent.  The  authors  havebtained  the  informed  consent  of  the  patients  and/oria  Published  by  Elsevier  España,  S.L.  All  rights  reserved.72  M.  Silva  Vieira  et  al.Figure  1  Electrocardiogram  (ECG)  showing  ST-segment  depression  and  T-wave  inversion  in  the  precordial  and  inferior  leads.Importantly, detailed  retrospective  analysis  of  the  admission  ECG  reveals  a  shift  of  the  frontal  QRS  to  the  right,  with  a  prominentS wave  in  lead  I  and  an  inverted  T  wave  in  lead  III,  as  well  as  low  QRS  voltage  in  the  right  precordial  leads  and  a  pseudoinfarctionpattern (Qr  in  V1  with  poor  R-wave  progression/excessive  clockwise  rotation  with  rS  up  to  V6),  an  indication  of  right  ventricularoverload/injury.Figure  2  Transthoracic  echocardiogram  in  left  parasternal  short-axis  view  depicting  a  dilated  right  ventricle  with  leftward  septalshift, suggestive  of  right  ventricular  pressure  overload  (A).  Parasternal  short-axis  view  of  the  basal  right  ventricle  (RV)  (B)  and  RVmodiﬁed apical  4-chamber  view  (C  and  D)  showing  a  dilated  right  ventricle  and  a  free-ﬂoating  right  atrial  mass  (about  4.01  ×  1.96cm). Severe  tricuspid  regurgitation  due  to  annular  dilatation  (E)  and  dilated  inferior  vena  cava  with  no  respiratory  variation  (F)are also  shown;  estimated  systolic  pulmonary  pressure  was  54  mmHg  (not  shown).  The  ﬁndings  were  highly  suggestive  of  acutepulmonary embolism  with  incidental  right  heart  thromboembolus  in  transit.Figure  3  A  central  bilateral  intraluminal  ﬁlling  defect  (arrows)  is  seen,  consistent  with  pulmonary  emboli  (A  -- transaxial  view;  Ba en  inRsiCTADocument downloaded from http://www.elsevier.pt, day 04/11/2014. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.nd C  -- sagittal  views).  A  thromboembolus  (arrowhead)  is  also  seA: right  atrium;  RV:  right  ventricle;  SVC:  superior  vena  cava.ubjects  mentioned  in  the  article.  The  corresponding  authors  in  possession  of  this  document.onﬂicts of interesthe  authors  have  no  conﬂicts  of  interest  to  declare.Scd the  right  atrium  (C).  IVC:  inferior  vena  cava;  LV:  left  ventricle;ppendix. Supplementary materialupplementary  material  associated  with  this  arti-le  can  be  found  in  the  online  version  available  atoi:10.1016/j.repc.2012.07.008.

Embolia pulmonar com trombo-êmbolo em trânsito

http://repositorio.chporto.pt/bitstream/10400.16/1728/1/Pulmonary%20embolism%20with%20thromboembolus%20in%20transit.pdf

Embolia pulmonar com trombo-êmbolo em trânsito

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