Editorial comment
Thrombi in the right atrium with pulmonary embolism: About a clinical case
Trombos na aurícula direita com embolização pulmonar: a propósito de um caso clínico
José Eduardo Aguiar
Cardiology Functional Unit, North Alentejo Local Health Unit, Portugal
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It was decided to use an ultra-slow low-dose thrombolysis protocol, due to deterioration in the patient's clinical condition despite standard treatment with unfractionated heparin.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Regardless of clinical deterioration, intervention in patients with thrombi in the right atrium is urgent since thrombus embolization can occur at any time. Unfortunately, as the authors point out, the optimal management of right atrial thrombi remains controversial since there have been no randomized controlled trials comparing the different treatment options.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">However, it was decided to use an ultra-slow dose thrombolysis protocol, given the prohibitive surgical risk. Ultra-slow, low-dose thrombolytic therapy is documented most commonly in the treatment of prosthetic valve thrombosis, as in the TROIA and PROMETEE trials.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The authors demonstrated in this case that ultra-slow low-dose thrombolysis was a safe and effective treatment option. Although this method may provide an effective alternative option while limiting the risk of thrombus dislodgment, some authors have pointed out the possible increased risk of embolization arising from lysis of the point where the thrombus is attached to the right atrial wall.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Echocardiography, considered the gold standard diagnostic tool for intracardiac thrombi, is also the mainstay of embolic risk assessment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the absence of controlled trials, the best therapeutic strategy should be decided on a case-by-case basis by a multidisciplinary team, always taking into account factors specific to the patient, such as embolic, bleeding and surgical risk, availability of different therapeutic options, and the experience of the unit.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Take-home messages</span><p id="par0040" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0045" class="elsevierStylePara elsevierViewall">Thrombi in the right heart are seen in 18% of patients with pulmonary embolism, and over 40% mortality is associated with this presentation.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0050" class="elsevierStylePara elsevierViewall">Intervention for patients with thrombi in the right atrium is urgent, since thrombus embolization can occur at any time.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0055" class="elsevierStylePara elsevierViewall">The optimal management of right atrial thrombi remains controversial since there have been no randomized controlled trials comparing the different treatment options.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0060" class="elsevierStylePara elsevierViewall">Ultra-slow low-dose thrombolysis was a safe and effective treatment option for the management of right atrial thrombi.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0065" class="elsevierStylePara elsevierViewall">Echocardiography, considered the gold standard diagnostic tool for intracardiac thrombi, is also the mainstay of embolic risk assessment.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0070" class="elsevierStylePara elsevierViewall">In the absence of controlled trials, the best therapeutic strategy should be decided on a case-by-case basis by a multidisciplinary team.</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Take-home messages" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global burden of thrombosis: epidemiologic aspects" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.M. 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Biteker" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Am Coll Cardiol Imaging" "fecha" => "2013" "volumen" => "6" "paginaInicial" => "206" "paginaFinal" => "216" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultraslow thrombolytic therapy: a novel strategy in the management of PROsthetic Mechanical valve Thrombosis and the prEdictors of outcome: the ultra-slow PROMETEE trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "OzkanM" 1 => "S. Gunduz" 2 => "O.M. Gursoy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ahj.2015.04.025" "Revista" => array:6 [ "tituloSerie" => "Am Heart J" "fecha" => "2015" "volumen" => "170" "paginaInicial" => "409" "paginaFinal" => "418" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26299240" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000004200000011/v1_202311030625/S0870255123002652/v1_202311030625/en/main.assets" "Apartado" => array:4 [ "identificador" => "93357" "tipo" => "SECCION" "pt" => array:2 [ "titulo" => "Case Report" "idiomaDefecto" => true ] "idiomaDefecto" => "pt" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000004200000011/v1_202311030625/S0870255123002652/v1_202311030625/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255123002652?idApp=UINPBA00004E" ]
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