Percutaneous treatment of a free-floating thrombus in the right atrium of a patient with pulmonary embolism and acute my
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CASE REPORT
Percutaneous treatment of a free-floating thrombus in the right atrium of a patient with pulmonary embolism and acute myocarditis Tomoyasu Momose • Takehiro Morita Takuo Misawa
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Received: 24 December 2011 / Accepted: 5 October 2012 / Published online: 18 October 2012 Ó Japanese Association of Cardiovascular Intervention and Therapeutics 2012
Abstract Free-floating thrombi in the right atrium (RA) are extremely hazardous to patients with pulmonary thromboembolism, and optimal treatment methods remain unclear. We report a case of successful percutaneous intervention of a critical right atrial thrombus. The patient was a 50-year-old woman who had been under medication for acute myocarditis when she complained of sudden severe dyspnea. Echocardiography showed a mobile snakelike thrombus in the RA. The thrombus was pulled back to the distal inferior vena cava (IVC) using a catheter and an IVC filter was placed. Percutaneous treatment is useful for treating free-floating RA thrombi. Keywords Pulmonary thromboembolism Inferior vena cava filter Right atrial thrombus Endovascular thrombectomy Aspiration thrombectomy
Case presentation A 50-year-old woman with continuous high fever and back pain visited our hospital. She had no remarkable family or medical history. Her height was 150 cm, weight was 46 kg and blood pressure (BP) was 99/62 mmHg. A physical examination indicated low-grade fever, coarse crackles on both sides of the chest, and giant masses in the lower abdomen, which were thought to be hysteromyomas. A chest radiograph showed bilateral pleural effusion and
T. Momose (&) T. Morita T. Misawa Department of Cardiology, Nagano-Matsushiro General Hospital, Matsushiro 183, Matsushiro Town, Nagano 381-1231, Japan e-mail: [email protected]
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pulmonary congestion with a cardiothoracic ratio of 52 %. An electrocardiogram showed normal sinus rhythm with a heart rate (HR) of 90 bpm, complete right bundle branch block, ST elevation in aVL, V2 and V3 leads, and ST depression in II, III, aVF, V5 and V6 leads. Trans-thoracic echocardiography (TTE) revealed a diffusely hypokinetic left ventricle with an ejection fraction (EF) of 30 %. Levels of biomarkers of myocardial injury were elevated in blood chemistry: creatinine kinase was 1,654 IU/L, creatinine kinase-MB was 167 IU/L, lactate dehydrogenase was 714 IU/L, aspartate aminotransferase was 254 IU/L and troponin-I was 7.18 ng/mL (normal range: \ 0.1 ng/mL). The patient underwent emergency cardiac catheterization, and no significant stenosis was observed in coronary angiography. A left ventriculogram showed that the left ventricle was diffusely hypokinetic and that the end-diastolic and endsystolic volumes were 175 and 134 mL, respectively, and the EF was 23 %. Right heart catheterization showed that pulmonary capillary wedge pressure was 29 mmHg, pulmonary artery (PA) pressure was 36/27 mmHg and the cardiac index was 1.87 L/min/m2. Acute myocarditis was diagnosed and we initiated medical treatment with dobutamine (3–6 lg/kg/ mi
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