Português João, Calvo Lucy, Oliveira Margarida, Pereira Vítor Hugo, Guardado Joana, Lourenço Mário Rui, Azevedo Olga, Ferreira Francisco, Canário-Almeida Filipa, Lourenço António
Cardiology Department, Hospital Senhora da Oliveira, Guimarães, Portugal.
Escola de Ciências da Saúde, Universidade do Minho, Braga, Portugal.
Case Rep Cardiol. 2017;2017:9092576. doi: 10.1155/2017/9092576. Epub 2017 Apr 2.
Detection of right heart thrombi (RHT) in the context of pulmonary thromboembolism (PE) is uncommon (4-18%) and increases the risk of mortality beyond the presence of PE alone. Type A thrombi are serpiginous and highly mobile and are thought to be originated from large veins and captured in-transit within the right heart. Optimal management of RHT is still uncertain. A 79-year-old woman, with a history of recent total hysterectomy with adnexectomy and a Wells procedure, presented to the emergency department following an episode of syncope. Computed tomography revealed bilateral PE and the presence of a right atrial thrombus. Transthoracic echocardiography demonstrated a free-floating type A thrombus in the right atrium, protruding into the right ventricle, and signs of pulmonary hypertension and right ventricle dysfunction. Considering the recent surgery and clinical stability, treatment with heparin alone was decided. Subsequent clinical improvement was observed and echocardiographic follow-up revealed complete thrombus dissolution and complete recovery of right ventricle function. Most authors recommend treatment of PE with RHT with thrombolysis or embolectomy followed by anticoagulation, although evidence is scarce. Individual risk of hemorrhage and operatory-related mortality should be taken into account when defining the treatment strategy especially when benefit is not firmly established.
在肺血栓栓塞症（PE）背景下检测到右心血栓（RHT）并不常见（4%-18%），且会增加死亡率，其死亡率高于单纯存在PE时。A型血栓呈匐行状且高度可移动，被认为起源于大静脉并在右心内被捕获。RHT的最佳治疗方案仍不确定。一名79岁女性，近期有全子宫切除术加附件切除术及韦尔斯手术史，在一次晕厥发作后就诊于急诊科。计算机断层扫描显示双侧PE及右心房血栓。经胸超声心动图显示右心房内有一个游离漂浮的A型血栓，突入右心室，并有肺动脉高压和右心室功能障碍的迹象。考虑到近期手术及临床稳定性，决定仅用肝素治疗。随后观察到临床症状改善，超声心动图随访显示血栓完全溶解，右心室功能完全恢复。大多数作者建议对合并RHT的PE采用溶栓或栓子切除术治疗，随后进行抗凝治疗，尽管证据不足。在确定治疗策略时，尤其是在获益尚未明确确立时，应考虑个体出血风险和手术相关死亡率。
