Chapoutot L, Tassigny C, Nazeyrollas P, Poismans P, Maillier B, Maes D, Metz D, Elaerts J
Service de cardiologie A, CH de Charleville, Charleville-Mézières.
Arch Mal Coeur Vaiss. 1995 Nov;88(11 Suppl):1723-8.
In general, there are two types of right heart thrombi diagnosed by echocardiography: mobile and non-mobile thrombi, more often located in the atrium than in the ventricle and a potential source of pulmonary embolism. However, they differ in several points: clinical context, clinical and echocardiographic presentations, embolic potential, prognosis and treatment. The result of peripheral venous thrombosis, mobile thrombus it is usually diagnosed during echocardiographic investigation of pulmonary embolism. The appearances are often that of serpentine thrombus floating in the right heart chambers associated with signs of acute cor pulmonale. It is a marker of imminent and often fatal embolism as it completes a previous and usually severe pulmonary embolism; the mortality is over 40%. It is a contra-indication for pulmonary angiography because of the risk of embolism and a therapeutic emergency. Some groups advocate surgical embolectomy and others thrombolysis. Its precise frequency in the acute stage of pulmonary embolism and its treatment remain to be determined by a prospective, multicentre clinical trial. The adherent non-mobile thrombus is usually implanted on the free wall of the right atrium or the interatrial septum. Its formation, in situ, is due to stasis secondary to decompensated congenital or acquired cardiac disease or to the presence of an intracardiac foreign body such as a pacing wire. It is less likely to cause pulmonary embolism. It decreases or disappears with anticoagulant therapy and the outcome is usually good. The differential diagnosis between a mobile thrombus and a Chiari network, or between an adherent thrombus and a vegetation on a intracardiac pacing wire may be difficult and requires transoesophageal echocardiography. The investigation of pulmonary embolism requires systematic echocardiography, one of the objectives of which is to search for right sided thrombi.
一般来说，经超声心动图诊断的右心血栓有两种类型：活动型和非活动型血栓，更多位于心房而非心室，是肺栓塞的潜在来源。然而，它们在几个方面存在差异：临床背景、临床及超声心动图表现、栓塞潜能、预后和治疗。活动型血栓是周围静脉血栓形成的结果，通常在肺栓塞的超声心动图检查中被诊断出来。其表现通常为蜿蜒的血栓漂浮在右心腔内，并伴有急性肺心病的体征。它是即将发生且常为致命性栓塞的标志，因为它继发于先前通常较为严重的肺栓塞；死亡率超过40%。由于存在栓塞风险且属于治疗急症，它是肺血管造影的禁忌证。一些团队主张手术取栓，另一些则主张溶栓。其在肺栓塞急性期的确切发生率及其治疗仍有待前瞻性多中心临床试验来确定。附着的非活动型血栓通常附着于右心房游离壁或房间隔。其原位形成是由于先天性或后天性心脏病失代偿继发的血流淤滞，或由于心内异物如起搏导线的存在。它引起肺栓塞的可能性较小。抗凝治疗后其体积会减小或消失，预后通常良好。活动型血栓与奇亚里网之间，或附着型血栓与心内起搏导线上的赘生物之间的鉴别诊断可能困难，需要经食管超声心动图检查。肺栓塞的检查需要系统的超声心动图检查，其目的之一是寻找右侧血栓。
