A Free Floating Right Atrial Giant Thrombus Treated by Heparin on the Road to Pulmonary Arteries

Abstract

Free fl oating right atrial thrombi are associated with high mortality. Although trombolysis and surgical trombectomy are recommended, their management is still the subject of debate. A 78 year old woman with a history of stroke a month ago, presented to the emergency department with palpitation. Transthoracic echocardiography revealed a large free-fl oating right atrial thrombus. After intravenous bolus of 5000 IU unfractional heparin she was prepared for cardiac surgery because of contraindications for trombolytic therapy. About 90 minutes after unfractional heparininfusion, we decided to check the thrombus, and realised that it was not there anymore, but there was a slight enlargement in right cardiac chambers. Patient was hemodynamically stabil. Contrast enhanced computerized tomography demonstrated multiple small fi lling defects in the subsegmental branches of pulmonary tree. Surgery was cancelled and Doppler ultrasonography revealed deep venous thrombosis in the left lower limb. After 72 hours of continuous unfractional heparin infusion, warfarin was started. During the hospitalization there was not any complication. Patient was stabil for the following three months. This is a report of free fl oating right atrial trombus origined from deep lower extremity veins and treated by unfractional heparin without any clinical deterioration. In this particular case we think that unfractional heparin might have partly worked because of fresh, unorganised and fragil thrombus. In patients with right atrial free fl oating thrombus, especially when thrombolytic therapy is contraindicated and surgical mortality is high, it may be an alternative to start unfractional heparin and check the thrombus after several hours before the surgery.