DOWNLOAD PDF

Image in cardiology

References

Figure 1

Figure 2

Figure 3

SHARE

A Prolapsing Right Heart Thrombus

 

Shyam Shankar, MBBS, Abhishek Sharma, MD, On Chen, MD, Adnan Sadiq, MD

 

Division Department of Medicine, Maimonides Medical Center, NY. Division of Cardiovascular diseases, State University of New York, Downstate Medical Center, NY. Department of Cardiology, Maimonides Medical Center, NY

 

Image in cardiology

A 95 year old female with history of hypertension presented with acute onset dyspnea at rest. Electrocardiography for this patient was suggestive of right bundle branch block. Echocardiogram showed large mobile free floating serpentine masses in right atrium. This was associated with the pathognomonic findings of an akinetic right ventricular (RV) free wall and hyper-contractile apex (McConnell sign) (Figures 1, 2 and 3, videos 1 and 2). Computed tomography revealed an acute pulmonary embolus (PE) in right and left pulmonary arteries as well as right atrial and ventricular dilation, and a renal mass, suggesting malignancy. Patient was diagnosed with massive pulmonary embolism secondary to right heart thrombi originating from deep vein thrombosis (DVT) and anticoagulation was initiated. With respect to the request of the family, conservative management and hospice care were provided. McConnell et al. has described right ventricular wall dysfunction with preserved motion of the apex and abnormal wall motion of the mid-free wall on echocardiography as a highly specific finding in pulmonary emboli.(1) This is secondary to the tethering of the right ventricular apex to the hyperdynamic left ventricle. This echo also showed long, thin, mobile worm like thrombi, also known as type A thrombi, which is associated with a higher incidence of deep venous thrombosis. These have a worse prognosis, as compared to Type B thrombi (which are related to thrombogenic cardiac abnormalities).(2) These images illustrate the rare findings of both McConnell sign and thrombus in transit, and underline the important role of echocardiography in this setting (J clin invasive cardiol 2015;2(1):2-3). Key words: McConnell’s sign, thrombus in transit, pulmonary emboli.

 

Figure 1

Figure 1. Right ventricular inflow transthoracic echocardiography view, showed the large serpentine free floating thrombus prolapsing from right atrium to right ventricle through the tricuspid valve during diastole (mark). Movie 1 shows the echocardiogram of this phenomenon in the right ventricular inflow view.

 

Figure 2

Figure 2. A four chamber transthoracic echocardiography view during systole demonstrates the free floating thrombus (white star) in the right atrium and the hypercontractile apex in systole (white arrow). Movie 2 displays the McConnel sign with thrombus in transit in a four chamber view.

Figure 3

Figure 3. A four chamber view during diastole illustrates the free floating thrombus prolapsing into the right ventricle. The thrombus is freely mobile and does not have an attachment to any of the chamber walls.

References

1. McConnell MV, Solomon SD, Rayan ME, Come PC, Goldhaber SZ, Lee RT. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol 1996; 15;78(4):469-73.

2. Finlayson GN. Right heart thrombi: consider the cause. Can J Cardiol 2008;24:888.