April 2024 Issue
ISSN 2689-291X
ISSN 2689-291X
Peripartum IVC Thrombus:
A McConnell’s Prelude!
Description
The above 2-dimensional (2-D) transthoracic echocardiographic (TTE) images were obtained in the setting of estrogen treatment for surgical menopause induced by hysterectomy. This was following emergent cesarean section for significant bleeding in the third trimester of pregnancy due to placenta accreta. Panel A, subcostal view reveals a large thrombus in the inferior vena cava (IVC). Panel B, 2-D apical 4-chamber view, reveals dilatation and hypokinesis of the right ventricular (RV) free wall indicative of RV strain, with sparing of the apex. This is suggestive of acute cor pulmonale secondary to pulmonary embolism (McConnell’s sign) caused by the IVC thrombus. Post-operative Panel C subcostal view reveals absence of IVC thrombus with placement of an IVC filter, while Panel D reveals resolution of the RV strain and McConnell’s sign following surgical embolectomy.
Discussion
Estrogen use has long been associated with an increase in the risk of thrombosis [1], especially deep vein thrombosis and pulmonary embolism [2]. The route of estrogen administration seems to impact the risk of thromboembolism [3]. Women with hematologic disorders appear to have an elevated risk of treatment with hormonal therapies [4] and require special attention if such therapy is necessary.
Deep vein thrombi travel up the inferior vena cava (IVC) or, less commonly, down the superior vena cava (SVC) to reach the right heart on their way to the lungs. Intracardiac thrombi are rare findings on transthoracic echocardiograms (TTE) performed in the setting of pulmonary embolism, and are often referred to as clot-in-transit (CIT) [5] or right heart thrombus-in-transit (RHTIT) [6], often portending a poor prognosis.
For patients with CIT or RHTIT and coexisting pulmonary embolism, the mortality is high [7], and prompt diagnosis and treatment are crucial, preferably utilizing a multidisciplinary heart team approach. Therapeutic strategies include surgical embolectomy, thrombolytics, and heparin anticoagulation [8]. One earlier retrospective analysis revealed a superiority of thrombolytic therapy compared either to anticoagulation alone or surgery [9].
More recently, percutaneous aspiration of right atrial thrombi [10] and other masses [11] has been gaining momentum. Such procedures offer hope for patients who are not candidate for surgical embolectomy or thrombolytic therapy.
Conclusion
CIT and RHTIT, including visualized thrombi in the venae cavae, are rare echocardiographic findings encountered in a variety of settings. They herald a poor prognosis and mandate timely diagnosis and treatment to avoid fatal pulmonary embolism. Given the diverse patient profiles and comorbidities and the availability of a wide range of medical, interventional and surgical options, a patient-tailored approach utilizing an established multidisciplinary Heart Team is recommended [12].
References
The above 2-dimensional (2-D) transthoracic echocardiographic (TTE) images were obtained in the setting of estrogen treatment for surgical menopause induced by hysterectomy. This was following emergent cesarean section for significant bleeding in the third trimester of pregnancy due to placenta accreta. Panel A, subcostal view reveals a large thrombus in the inferior vena cava (IVC). Panel B, 2-D apical 4-chamber view, reveals dilatation and hypokinesis of the right ventricular (RV) free wall indicative of RV strain, with sparing of the apex. This is suggestive of acute cor pulmonale secondary to pulmonary embolism (McConnell’s sign) caused by the IVC thrombus. Post-operative Panel C subcostal view reveals absence of IVC thrombus with placement of an IVC filter, while Panel D reveals resolution of the RV strain and McConnell’s sign following surgical embolectomy.
Discussion
Estrogen use has long been associated with an increase in the risk of thrombosis [1], especially deep vein thrombosis and pulmonary embolism [2]. The route of estrogen administration seems to impact the risk of thromboembolism [3]. Women with hematologic disorders appear to have an elevated risk of treatment with hormonal therapies [4] and require special attention if such therapy is necessary.
Deep vein thrombi travel up the inferior vena cava (IVC) or, less commonly, down the superior vena cava (SVC) to reach the right heart on their way to the lungs. Intracardiac thrombi are rare findings on transthoracic echocardiograms (TTE) performed in the setting of pulmonary embolism, and are often referred to as clot-in-transit (CIT) [5] or right heart thrombus-in-transit (RHTIT) [6], often portending a poor prognosis.
For patients with CIT or RHTIT and coexisting pulmonary embolism, the mortality is high [7], and prompt diagnosis and treatment are crucial, preferably utilizing a multidisciplinary heart team approach. Therapeutic strategies include surgical embolectomy, thrombolytics, and heparin anticoagulation [8]. One earlier retrospective analysis revealed a superiority of thrombolytic therapy compared either to anticoagulation alone or surgery [9].
More recently, percutaneous aspiration of right atrial thrombi [10] and other masses [11] has been gaining momentum. Such procedures offer hope for patients who are not candidate for surgical embolectomy or thrombolytic therapy.
Conclusion
CIT and RHTIT, including visualized thrombi in the venae cavae, are rare echocardiographic findings encountered in a variety of settings. They herald a poor prognosis and mandate timely diagnosis and treatment to avoid fatal pulmonary embolism. Given the diverse patient profiles and comorbidities and the availability of a wide range of medical, interventional and surgical options, a patient-tailored approach utilizing an established multidisciplinary Heart Team is recommended [12].
References
- Abou-Ismail MY, Citla Sridhar D, Nayak L. Estrogen and thrombosis: A bench to bedside review. Thromb Res. 2020 Aug;192:40-51.
- Grady D, Sawaya G. Postmenopausal hormone therapy increases risk of deep vein thrombosis and pulmonary embolism. Am J Med. 1998 Jul;105(1):41-3.
- ACOG committee opinion no. 556: Postmenopausal estrogen therapy: route of administration and risk of venous thromboembolism. Obstet Gynecol. 2013 Apr;121(4):887-890.
- Baldwin MK, Samuelson Bannow B, Rosovsky RP, Sokkary N, Srivaths LV. Hormonal therapies in females with blood disorders: thrombophilia, thrombosis, hemoglobinopathies, and anemias. Res Pract Thromb Haemost. 2023 Apr 24;7(4):100161.
- Igwilo R, Pinsino A, Aksan F, Kapoor S. Clot-in-transit: A ticking time bomb in the heart with serious consequences. SAGE Open Med Case Rep. 2023 Feb 7;11:2050313X231151504.
- Otoupalova E, Dalal B, Renard B. Right heart thrombus in transit: a series of two cases. Crit Ultrasound J. 2017 Dec;9(1):14.
- Zieliński D, Zygier M, Dyk W, Wojdyga R, Wróbel K, Pirsztuk E, Szostakiewicz K, Szatkowski P, Darocha S, Kurzyna M, Ciurzyński M, Machowski M, Pruszczyk P, Torbicki A, Biederman A. Acute pulmonary embolism with coexisting right heart thrombi in transit-surgical treatment of 20 consecutive patients. Eur J Cardiothorac Surg. 2023 Apr 3;63(4):ezad022.
- Bhargava M, Dincer E. Traveling thrombus in the right atrium: is it the final destination? Case Rep Pulmonol. 2012;2012:378282.
- Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest. 2002 Mar;121(3):806-14.
- Tyrka A, Stepniewski J, Hymczak H, Szlósarczyk B, Komar M, Filip G, Waligóra M, Podolec P, Drwiła R, Kapelak B, Kopeć G. Percutaneous aspiration of a right atrial thrombus with the AngioVac system. Cardiol J. 2023;30(3):491-492.
- Riad M, Rahman MU, Mulyala R, Sayyed N, Bayer D, Omar B. Percutaneous Intracardiac Mass Extraction in High Surgical-Risk Patients. J Med Cases. 2023 Nov;14(11):362-368.
- Mazza A, Iafrancesco M, Bruno P, Chiariello GA, Trani C, Burzotta F, Cammertoni F, Pasquini A, Diana G, Rosenhek R, Liuzzo G, Rabini A, Flex A, Raweh A, Crea F, Massetti M. The multidisciplinary Heart Team approach for patients with cardiovascular disease: a step towards personalized medicine. J Cardiovasc Med (Hagerstown). 2023 Dec 1;24(12):906-913.
Authors:
William Smith, B.S.
Medical Student
University of South Alabama
Mobile, AL
Mustafeez Ur Rahman, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Nupur Shah, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Christopher Malozzi, D.O.
Associate Professor of Cardiology
University of South Alabama
Mobile, AL
Bassam Omar, M.D., Ph.D.
Professor of Cardiology
University of South Alabama
Mobile, AL
William Smith, B.S.
Medical Student
University of South Alabama
Mobile, AL
Mustafeez Ur Rahman, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Nupur Shah, M.D.
Cardiology Fellow
University of South Alabama
Mobile, AL
Christopher Malozzi, D.O.
Associate Professor of Cardiology
University of South Alabama
Mobile, AL
Bassam Omar, M.D., Ph.D.
Professor of Cardiology
University of South Alabama
Mobile, AL