From the Guidelines
A thrombus in the right heart requires immediate medical attention, and treatment typically involves anticoagulation therapy with heparin, followed by oral anticoagulants, with consideration of thrombolytic therapy or surgical thrombectomy in certain cases. The presence of right heart thrombi, especially mobile ones, is associated with increased early mortality and a high risk of recurrent pulmonary embolism 1. The treatment of choice is controversial, but anticoagulation alone seems to be insufficient, and thrombolysis or embolectomy may be necessary in certain cases 1.
Key Considerations
- The size and mobility of the thrombus, as well as the patient's hemodynamic status, are important considerations in deciding on the treatment approach 1.
- Anticoagulation therapy with heparin, followed by oral anticoagulants such as warfarin or direct oral anticoagulants like rivaroxaban, may be appropriate in most cases 1.
- Thrombolytic therapy with tissue plasminogen activator (tPA) may be necessary in hemodynamically unstable patients, and surgical thrombectomy may be considered for massive thrombi causing severe obstruction 1.
- Echocardiography should be performed to assess thrombus size, location, and cardiac function, and the underlying cause of the thrombus must be identified and addressed 1.
Treatment Approach
- Anticoagulation therapy: heparin (either unfractionated or low molecular weight heparin) followed by oral anticoagulants (warfarin or direct oral anticoagulants like rivaroxaban) for at least 3-6 months.
- Thrombolytic therapy: tissue plasminogen activator (tPA) at 100 mg over 2 hours may be necessary in hemodynamically unstable patients.
- Surgical thrombectomy: may be considered for massive thrombi causing severe obstruction.
Important Notes
- Right heart thrombi are dangerous because they can embolize to the lungs, causing potentially fatal pulmonary embolism, which is why prompt treatment is essential to prevent this life-threatening complication 1.
- The natural history of right atrial thrombosis in different patient subgroups needs to be determined, and the impact of thrombosis size and mobility on natural history needs to be determined 1.
From the Research
Thrombus in the Right Heart
- A right heart thrombus is a challenging and high-mortality disease, often seen in the setting of pulmonary embolism 2.
- Traditional treatments for right heart thrombus have included anticoagulation, thrombolysis, and surgical embolectomy 2, 3.
- Advances in endovascular therapies have led to the development of novel devices and strategies for treating right heart thrombus, including large bore aspiration thrombectomy systems 2.
- These endovascular therapies are increasingly becoming the preferred method of treatment due to their ability to rapidly debulk the thrombus and lower morbidity 2.
Diagnosis and Management
- Right heart thrombus can be diagnosed using two-dimensional echocardiography, which can also show evidence of right heart dysfunction in patients with major pulmonary thromboembolism 3.
- The management of right heart thrombus depends on the individual patient's condition, but may include surgical removal of the thrombus, anticoagulation, or a combination of both 3.
- Anticoagulant medications, such as heparins and vitamin K antagonists, are commonly used to prevent and treat venous thromboembolism, including right heart thrombus 4, 5.
Treatment with Anticoagulation
- Anticoagulation therapy is recommended for preventing, treating, and reducing the recurrence of venous thromboembolism, including right heart thrombus 5.
- Direct oral anticoagulants are first-line agents for eligible patients, while vitamin K antagonists are recommended for patients with mechanical valves and valvular atrial fibrillation 5.
- The use of unfractionated heparin for anticoagulation in patients with pulmonary embolism has been studied, with results showing that many patients spend most of their first 48 hours outside of the therapeutic range 6.