Leclercq F, Messner-Pellenc P, Beigbeder J Y, Albat B, Thévenet A, Grolleau-Raoux R
Service de cardiologie A, hôpital Arnaud de Villeneuve, Montpellier.
Arch Mal Coeur Vaiss. 1994 Jun;87(6):805-11.
Mobile right atrial thrombi carry a high risk of pulmonary embolism which may be massive and are a medical emergency. Although surgery is commonly indicated, treatment with intravenous thrombolytics is an alternative and was successful in 4 out of 6 cases reported by the authors. Six patients, admitted for severe pulmonary embolism confirmed by pulmonary scintigraphy (6 cases) and by angiography (2 cases), underwent echocardiography which demonstrated a mobile right atrial thrombus. One patient was operated as an emergency and died immediately afterwards. Another, treated with heparin because of contraindications to surgery and thrombolysis had a recurrent fatal pulmonary embolism. In the other four cases, intravenous thrombolytic therapy was started immediately after echocardiography with 250,000 IU of streptokinase in 30 minutes, followed by 100,000 IU per hour for 48 to 72 hours associated with heparin 300 to 500 IU/kg/day. The biological efficacy of the treatment was confirmed in all cases (fibrinogen < 1 milligram; TCA > 60 s). A clinical improvement with improved blood gases was rapidly obtained in all 4 cases. The thrombus had totally disappeared at control echocardiography 8 to 12 hours after the initial examination. There were no complications, in particular no haemorrhages. After 6 months' follow-up, the outcome was good with oral anticoagulants (4 cases) associated with implantation of a caval filter in 1 case. Thrombolysis seems to be an effective alternative to surgery as there four cases demonstrate.
右心房移动性血栓具有很高的肺栓塞风险，可能引发大面积肺栓塞，属于医疗急症。虽然通常建议进行手术，但静脉溶栓治疗是一种替代方法，作者报告的6例中有4例治疗成功。6例因肺灌注显像（6例）和血管造影（2例）确诊为严重肺栓塞而入院的患者接受了超声心动图检查，结果显示右心房有移动性血栓。1例患者作为急诊接受手术，术后立即死亡。另1例因手术和溶栓治疗存在禁忌证而接受肝素治疗，发生复发性致命性肺栓塞。在其他4例中，超声心动图检查后立即开始静脉溶栓治疗，30分钟内静脉注射链激酶250,000 IU，随后每小时注射100,000 IU，持续48至72小时，并联合应用肝素300至500 IU/kg/天。所有病例均证实治疗具有生物学疗效（纤维蛋白原<1毫克；凝血酶时间>60秒）。所有4例患者的血气均迅速改善，临床症状好转。初次检查后8至12小时复查超声心动图时血栓已完全消失。未出现并发症，尤其是无出血情况。随访6个月后，4例口服抗凝剂患者预后良好，1例植入了下腔静脉滤器。正如这4例所示，溶栓似乎是手术的一种有效替代方法。
