Movable huge serpentine intracardiac thrombus in right atrium and massive pulmonary embolism: A rare manifestation of deep vein thrombosis

Authors: Zografidou P^1*, Mpliamplias D², Koraki E³

¹MD, MSc, Anesthesiology
²MD, MSc (RΜ), MSc (TAT), PEMS, Anesthesiology
³MD, MSc, PhD, Anesthesiology

Department of Anesthesiology, General Hospital “Papageorgiou”, Thessaloniki, Greece

*Correspondance: General Hospital of Thessaloniki “Papageorgiou”, Municipality of Pavlos Melas, N. Efkarpia, 56403, email: , tel.: 00306940915003.

ABSTRACT

Pulmonary embolism is linked with a remarkable rate of mortality, particularly when it is associated with hemodynamic instability, right atrial thrombus and related right ventricular dysfunction. Intraoperative use of transesophageal echocardiography can lead to the diagnosis of massive thrombi, entrapped in patent foramen ovale. We report a case of a patient who is already receiving low-molecular-weight heparin for a gamma knife removal of a thalamic lesion and found with massive pulmonary embolism and multiple thrombi in the right atrium. We demonstrate the usefulness of transesophageal echocardiography during the operation for diagnosis and guidance.

INTRODUCTION

Brain abscesses are now far less common compared than they were in the past, where was considered a relatively common disease with poor outcome. However, they continue to constitute one of the most important neurological emergencies. Thalamic and basal ganglia abscesses are unusual but treatable conditions^1,2. Only a few series of such inflammatory lesions have been reported. Their incidence varies from 1.3% to 6 % of all reported brain abscesses. Thalamic abscesses are typically of hematogenous origin, most commonly pulmonary, cardiac and cryptogenetic. The presence of a pulmonary arteriovenous shunt or unrecognized cardiac septal defects, or a patent foramen ovale, have been indicated as possible sources of so-called cryptogenic brain abscesses¹.

Diﬀerent treatments have been reported in the literature, including stereotactic aspiration with or without continuous drainage, repeated aspiration, freehand aspiration through a burr hole, stereo-endoscopic aspiration, ultrasound-guided aspiration, a surgical transventricular approach and pharmaceutical therapy alone.

Computed Tomography (CT) – guided stereotactic aspiration, as a ﬁrst-line treatment, with subsequent drainage and systemic therapy using targeted antibiotics seems to be the treatment of choice, to obtain a rapid and eﬀective decompression of the abscess, with a low risk of spreading the infection^1-3.

In the past few decades, stereotactic radiosurgery (SRS) techniques have changed the clinical treatment paradigms, in managing neuro-oncology patients. SRS offers improved treatment options for patients with brain metastatic disease, introducing a major shift away from the use of whole brain radiation in many patients⁴.

After the subsequent drainage of the thalamic abscess, patients discharge from the hospital with a prophylactic dose of low-molecular-weight heparin (LMWH) and the targeted antibiotics. LMWH is a class of medication used as an anticoagulant in diseases that feature thrombosis, as well as for prophylaxis in situations that lead to a high risk of thrombosis.

Case report

A 49 years old female patient, with body mass index (BMI) value of 30.4, presented at the emergency department of our hospital complaining of insisting pain in the right lower extremity (LE). Her surgical history, revealed two caesarean sections, a gamma knife stereotactic radiosurgery treatment of an intracerebral hemangioma (32 years ago) and a second gamma knife stereotactic radiosurgery for a thalamic lesion, two weeks before her emergent admission in our hospital. After discharge from the second surgery, she was under treatment with two different antibiotic categories and LMWH. She had no other past medical history.

Physical examination at the emergency department reveled swelling of the right calf with erythema, edema, tenderness, and positive Homans’ sign. Also, her Glasgow coma score (GCS) (GCS) was 15/15, systolic/diastolic blood pressure of 110/65 mmHg, oxygen saturation (SpO₂) was 98% and heart rate (HR) 88 bpm. A color Doppler ultrasound of the lower extremity was executed, which gave the first diagnosis of Deep Vein Thrombosis (DVT). A further simultaneous diagnostic series of both laboratory and CT Scan tests were performed, which revealed D-Dimers 3240,00 ng/ml, thrombus in the external iliac, common and superficial femoral veins and a massive Pulmonary Embolism (PE) respectively (Image 1).

Image 1. Computed Tomography (CT): Massive Pulmonary Embolism.

The patient’s hemodynamic status was stable despite the above findings. Urgently a transesophageal echocardiography (TEE) was requested, which gave the diagnosis of multiple and movable thrombi in the right heart chambers-with one of them to be located through a Patent Foramen Ovale (PFO) (diameter > 3cm), in the left atrium. The cardiothoracic surgical team was informed and the patient was transferred to the Operation Room (OR) for an open thrombectomy.

During her immediate admission in the OR the patient’s systolic/diastolic blood pressure was 160/90 mmHg (without administering any vasoconstrictor infusion), HR was 85 bpm and SpO₂ 98% (oxygen mask at 5 lit/min O₂). A 5 lead electrocardiogram (ECG), a 18G peripheral intravenous catheter and a right radial artery catheter were placed, in order to establish continuous monitoring, fluid administration and invasive blood pressure assessment. Induction of anesthesia and endotracheal intubation were established by administering intravenously 200 mg Propofol, 0.25 mg Fentanyl and 20 mg Cis-atracurium. Then, a Swan-Ganz catheter was inserted via patient’s right jugular vein, in order to evaluate central venous blood saturation (SvO₂) and continuous cardiac output (CCO). Bispectral index monitor (BIS) was also placed. Anesthesia was maintained using TIVA with propofol/remifentanil, both administered via the central venous catheter. After anesthesia induction and simultaneous with surgeon’s first cut, a TEE was performed in the OR, by the leading anesthesiologist. Using TEE, we confirmed the large floating thrombi in the right chambers and established the diagnosis of one of them to be located in the left atrium through a PFO. Furthermore, we confirmed the mobility and normal function of all valves. All these findings, provided by TEE, dictated the surgeon’s plan on the operating process, which was a cardiovascular bypass with right atriotomy. The serpentine shape thrombus was extracted with gentle traction through the right atrium without difficulty and it is shown at Image 2 and Image 3.

Image 2. Serpentine shape thrombus in the right atrium.

Image 3. Large serpentine thrombus.

The cross clamp time was 35 min and weaning from cardiopulmonary bypass was safe and successful. Postoperatively, the patient was under low inotropic support, which was successfully weaned the second postoperative day. Also, during the second postoperative day, patient was successfully extubated. Before her discharge from the hospital, a fully routine investigation-complete blood count, liver function test, renal function tests-were done along with and serum homocysteine, protein C, protein S, level of carcinoembryonic antigen (CEA), Carbohydrate antigen (CA) 19-9, cancer antigen (CA) 125. Test results did not lie outside the laboratory reference ranges and were considered to be normal.

DISCUSSION

Deep vein thrombosis (DVT) is the third most common cause of death, after myocardial infarction and stroke. It accounts for 80 cases of DVT in 100,000 people. Among these DVT cases, a few develop pulmonary embolism ^5,6.

As the deep veins of the lower limb are thick and slender, when the thrombus gets dislodged from these lower limbs, it takes a serpentine shape in the right atrium (RA). Hence, the serpentine thrombus seen in the RA is a tell-tale sign of the thrombus having origin from the deep veins. These serpentine thrombi account for 28% of death in hospitals, caused by serpentine thrombus leading to pulmonary embolism.

Varied presentations of pulmonary embolism have been reported. Here, we have reported a case of a patient having serpentine pulmonary embolism due to venous thromboembolism and its management.

The Virchows triad plays a crucial role in the development of DVT. The endothelial damage, hypercoagulability and stasis of blood result in the formation of a thrombus that gets lodged in the veins of the lower limb resulting in pulmonary embolism. The various etiologies responsible for this hypercoagulability is protein C, S deficiency, factor V Leiden mutation, raised serum homocysteine levels or it could be acquired due to cancer, pregnancy, chemotherapy or obesity. This thrombus can get dislodged by trauma or activity and by circulation can get clogged into the major arteries or can even reach the heart. Thrombus from the deep veins of the lower limb results in a serpentine thrombus in the RA, due to its retained shape. The serpentine clots seen in the RA are the pathognomic signs of DVT. This clot results in pulmonary embolism and commands urgent treatment. Acute pulmonary embolism causing this pulmonary vascular obstruction and vasoconstriction results in an increase in right ventricular afterload, thereby leading to the rise of pulmonary artery pressure, right ventricular dilatation and to the decrease in the stroke volume⁷.

There are many well-recognized risk factors for PE. These include the presence of deep venous thrombosis, previous surgical procedures (major general/orthopedic surgery), trauma (major fracture), hypercoagulable disorders (factor V Leiden and prothrombin mutations), malignancy (chemotherapy), and long-standing immobilization⁸.

However, there are also many other common predisposing conditions, including advanced age, obesity, smoking, stroke, congestive heart failure, respiratory failure, sepsis, inflammatory bowel disease, pregnancy, hormone replacement therapy, and use of oral contraceptive agents⁸.

The main goal of the treatment for massive PE is elimination of the embolic material and prevention of recurrent PE. The optimal therapeutic strategies for patients with acute PE still remain controversial, because there are no randomized controlled trials supporting an ideal treatment modality⁸. Current indications for surgical pulmonary embolectomy include patients with massive central PE and contraindications to thrombolytics or those who are hemodynamically unstable or who had right ventricle (RV) dysfunction after receiving thrombolytic therapy⁹. In addition, patients with free- floating thrombus within the right atrium or RV and patients in whom a PFO poses an imminent risk for paradoxical embolization, also require surgical embolectomy.^9,10

The occurrence of PE as an extension of DVT is infrequent in patients treated well with anticoagulation. The topical propagation of DVT is common and could be part of the natural history of VTE, as a prolonged inflammatory and remodeling process. In randomized controlled trials that included serial screening imaging studies (venous duplex or venography) after DVT diagnosis, the risk of asymptomatic topical DVT propagation in the first 10 days of therapy was 4.7% and 1.1% in unfractionated heparin (UFH) and LMWH, respectively, and these may reach up to 30% to 38% in some other studies (most of these cases had subtherapeutic anticoagulation). The risk of symptomatic topical DVT propagation is 0.3% and 0.6% for UFH and LMWH, respectively. The data for asymptomatic and symptomatic PE propagation are less known, and the reliable estimates of developing fatal PE from acute DVT are nonexistent¹¹.

Conclusion

Venous thromboembolism (VTE) includes both venous thrombosis and pulmonary embolism (PE). It is associated with significant morbidity and mortality. Patients with treated VTE present a 30-day mortality rate of 3%, while patients with untreated VTE show a significantly higher 30-day mortality rate of 31%. Despite being on therapeutic doses of anticoagulation, patients can still develop recurrent PE, which is appropriately termed “anticoagulation failure.” The rate of recurrent PE is up to 4% with low-molecular-weight heparin (LMWH) and 2-4% with vitamin K antagonists (VKA)¹². Transesophageal echocardiography (TEE) is a relatively recent development in imaging. The utilization of TEE in perioperative cardiac anaesthetic care has resulted in a considerable change in the role of the anaesthetist, who may use TEE to provide new information that may influence the course and outcome of surgical procedures. Perioperative transesophageal echocardiography is highly accurate in diagnosing structural anomalies, providing consistent and repeatable outcomes. The information obtained from TEE influences important therapeutic decisions in valvular surgery, coronary artery surgery, and thoracic aortic surgery¹³.

Addittional materials: No

Acknowledgements: Not applicable

Authors’ contributions: ZP: data collection, planning, literature review, manuscript preparation, final draft, is the lead author, MD: literature review, manuscript preparation, critical review, KE: supervision, critical review. All authors read and approved the final manuscript.

Funding: Not applicable

Availability of supporting data: Not applicable.

Consent for publication: Patient’s consent was obtained

Ethical approval and consent to participate:

No IRB approval required.

Competing interests: The authors declare that they have no competing interests.

Received: May 2024, Accepted: May 2024, Published: July 2024.

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Citation: Zografidou P, Mpliamplias D, Koraki E. Movable huge Serpentine Intracardiac Thrombus in the right atrium and massive Pulmonary Embolism: A rare manifestation of Deep vein thrombosis. Greek e j Perioper Med. 2024;23(b): 22-29.

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