Treatment of Infected Right Atrial Thrombus
For infected right atrial thrombus, surgical removal of the thrombus combined with appropriate antimicrobial therapy is the recommended treatment approach. 1, 2
Diagnosis
- Transesophageal echocardiography (TEE) is recommended as the diagnostic method of choice for detecting right atrial thrombi, especially when a prosthetic heart valve or intracardiac device is present 1
- Transthoracic echocardiography (TTE) should be performed as the first-line imaging modality, but has lower sensitivity for detecting smaller thrombi 1, 3
- Repeat echocardiography (TTE and/or TOE) within 5-7 days is recommended if initial examination is negative but clinical suspicion remains high 1
Treatment Approach
Surgical Management
- Surgical removal of the infected thrombus is the primary treatment of choice as antibiotics alone are insufficient for treating infected thrombi 2
- Urgent surgery is indicated for locally uncontrolled infection (abscess, false aneurysm, fistula, enlarging vegetation) 1
- Surgery should be considered in cases with persistent tricuspid valve vegetations >20 mm after recurrent pulmonary emboli 1
Antimicrobial Therapy
- Appropriate antimicrobial therapy should be administered based on blood culture results and susceptibility testing 1
- Initial empiric antimicrobial therapy should cover both gram-positive and gram-negative microorganisms until culture results are available 1
- Prolonged antibiotic therapy is recommended, especially when the thrombus is associated with a cardiac device 1
Anticoagulation Considerations
- In patients with infective endocarditis, routine anticoagulant therapy is not recommended unless a separate indication exists 1
- Similarly, routine antiplatelet therapy is not recommended in patients with infective endocarditis unless there is a separate indication 1
- For patients already on anticoagulation therapy who develop infective endocarditis, anticoagulation should be discontinued at the time of initial presentation and reinstated when the patient is deemed stable without contraindications or neurologic complications 1
Alternative Approaches
Catheter-Directed Thrombolysis
- In selected cases where surgery is contraindicated or high-risk, catheter-directed thrombolysis with recombinant tissue plasminogen activator (tPA) may be considered as an alternative treatment 4
- This approach provides the theoretical advantage of decreased risk of major bleeding by reducing exposure to high-dose systemic thrombolytic therapy 4
Device-Related Thrombi
- For infected thrombi related to cardiac devices (such as pacemakers), complete hardware removal along with prolonged antibiotic therapy is recommended 1
- Percutaneous extraction is recommended in most patients with cardiac device-related infective endocarditis, even those with vegetations >10 mm 1
Special Considerations
- Right atrial thrombi are associated with a high mortality rate, particularly when infected 2, 5
- Risk factors for right atrial thrombus formation include central venous catheters, pacemakers, and other indwelling devices 5
- Complications of right atrial thrombi include pulmonary embolism, septic emboli, mechanical problems of cardiac function, and systemic embolization in cases with atrial septal defect or patent foramen ovale 5