Case report: Emergent percutaneous directional thrombectomy in a patient with cardiogenic shock and large mobile thrombus in the right atrium.
Sara Blasco-Turrión, María Plaza-Martín, Ignacio J Amat-Santos- Cardiology and Cardiovascular Medicine
Background
New percutaneous techniques for the management of acute pulmonary embolism (PE) are emerging, but there is lack of data regarding the approach of mobile thrombus in the right chambers, with the added risk of potential thrombus dislodgement which may prevent from mechanical circulatory support devices to be implanted in unstable patients.
Case summary
We present the case of a 65-year-old male with cardiogenic shock of unknown etiology, severe biventricular dysfunction, and large mobile thrombus in the right atrium. Mechanical circulatory support devices could not be implanted and current thromboaspiration systems were either too small or not available at that time. However, the patient's condition deteriorated rapidly with thrombus in transit, hence a novel approach was required: using a deflectable 14Fr sheath, directional thrombectomy was performed, achieving complete extraction of the thrombi and allowing for circulatory support with ECMO to be implanted with outstanding results and progressive weaning of all intensive care measures.
Discussion
Despite the growing interest in the development of percutaneous strategies for acute PE, there is no evidence-based guidelines regarding the treatment of mobile right heart thrombus. Even though some cases of percutaneous right heart thrombectomy have been reported it is still a challenging scenario, given the potential risk of thrombus dislodgement and atrial perforation. We describe a novel technique of percutaneous directional thrombectomy in a patient with cardiogenic shock of unknown etiology and large mobile thrombi in the right atrium as bridge to ECMO proving to be a feasible alternative to treat thrombus in transit.