European Heart Journal (1990) 11, 863-865
V. DALL’AGLIO, G. L. NICOLOSI AND D. ZANUTTINI
Divisione di Cardiologia, Ospedale ’Santa Maria degli Angeli’, Pordenone, Italy
In this paper, we report a case of dilated cardiomyopathy with right atrial thrombi and pulmonary artery thromboemboli, in which regression of thromboemboli followed fibrinolytic therapy, and normalization of left ventricular dimensions and function were documented at echocardiographic follow-up. The important role of transoesophageal echocardiography in diagnosis and follow-up of right intracavitary masses and thrombo emboli in the main pulmonary arteries is discussed, as is the role of echocardiography in follow-up of car diomyopathy.
Submitted for publication on 31 July 1989, and in revised form 13 November 1989.
Correspondence: Dr. Vittorio Dall’Aglio
We report a case of dilated cardiomyopathy of unknown etiology with right atrial thrombosis and pulmonary artery thromboemboli, in which regression of thromboemboli was achieved by fibrinolysis, and normalization of left ventricular dimensions and function were documented by echocardiography.
G.A., a 50-year-old man, was admitted for dyspnoea and tachyarrhythmia without fever. On admission, the patient had pulmonary oedema and the ECG showed atrial fibrillation with a mean ventricular response of 130 beats min[-1] and left ventricular hypertrophy with secondary repolarization changes. Chest X-ray showed cardiomegaly with pulmonary oedema and bilateral pleural effusion. The patient denied excessive consumption of alcohol and was normotensive.
Two-dimensional echocardiographic examination (Fig. 1, left) showed a dilated and poorly contracting left ventricle, as well as a highly mobile mass in the right atrium. To facilitate analysis of this mass, a transoesophageal echocardiogram was performed (Fig. 2), which showed multiple thrombotic masses floating freely in the right atrium and sometimes protruding, during diastole, into the tricuspid orifice. During the examination (Fig. 2), two thromboembolic masses in the right pulmonary artery were also demonstrated. A lung scan performed the day after admission showed a pattern consistent with bilateral embolism.
Because of very poor left ventricular function and the associated high risk during surgery, cardiac surgery was not considered. Fibrinolytic therapy was started (urokinase, 3 000 000 IU day[-1]). After 3 days of this therapy, a second transoesophageal echocardiogram (Fig. 3) showed that the thromboembolic masses had disappeared; fibrinolytic therapy was then stopped. A second lung scan, performed after the fibrinolytic therapy, was normal.
After the disappearance of thromboemboli, sinus rhythm was restored with D.C. countershock. The echocardiogram performed on the day before discharge confirmed marked left ventricular dilatation and poor pump function (Fig. 1, middle); no mass was visible in the right or left cavities. The patient was discharged on antiarrhythmics, diuretics, vasodilators, digitalis and acenocoumarin. The last echocardiogram, performed 2 months later (Fig. 1, right) showed normalization of left ventricular dimensions and function.
Figure 1 Transthoracic echocardiograms at admission (left), the day before the patient’s discharge (middle) and 2 months later (right). Apical four-chamber views in diastole (D) and systole (S). A dilated and poorly contracting left ventricle is evident on the first and second echocardiograms. At admission, an apparently linear and free-floating formation (arrowheads) of low echogenicity is visible in the right atrium, adherent to the interatrial septum. 2 months after discharge (right), normalization of left ventricular dimensions and function was evident, as well as mild left ventricular hypertrophy.
Right heart thrombosis is a challenge to therapy; there is no agreement on the optimal treatment of this condition. Although right-sided heart thrombus detected on an echocardiogram is unusual in patients with pulmonary embolism, it is an important finding because it appears to identify a subset of patients who have a poor prognosis[1-2]. Recently, three cases of pulmonary embolism and associated mobile right atrial thrombus were successfully treated by thrombolysis. In our case, surgical removal of thromboemboli was considered too risky, owing to very poor left ventricular function. In such cases, fibrinolytic therapy could thus be considered reasonable.
Another intriguing and interesting aspect of this case is the normalization of left ventricular dimensions and function; in analogy with other cases studied in our laboratory, one can postulate a cause-effect relationship between alcohol intake suppression and left ventricular normalization (although the patient denied excessive consumption of alcohol), supposing an alcoholic origin of the
dilated cardiomyopathy. We cannot however exclude a regression of a myocarditis, even if the clinical picture did not indicate this etiology.
Another hypothesis on the origin of the dilated cardiomyopathy is that of’stunning’ of left ventricular myocardium induced by the atrial tachyarrhythmia; the stable maintenance of sinus rhythm might have produced a gradual normalization of left ventricular dimensions and function.
Transthoracic echocardiography, in our case, allowed diagnosis and follow-up of the right atrial masses and dilated cardiomyopathy. Transoesophageal echocardiography allowed better visualization of the right atrial masses, than transthoracic, making a clearer differential diagnosis between right atrial tumours and thrombi possible. Transoesophageal echocardiography, moreover, allowed the visualization of thromboemboli in the right pulmonary artery, as well as the demonstration of regression of these thrombotic and thromboembolic masses after fibrinolytic therapy.
Figure 2 Transoesophageal echocardiogram at the admission of the patient. (A) In the right atrium (ra) multiple, polylobulate thrombotic masses are evident. tv=tricuspid valve, rv= right ventricle. (B) Two thromboembolic masses (arrows) are visible in the right pulmonary artery (rpa).
svc = superior vena cava, ao = aorta.
Figure 3 Transoesophageal echocardiogram performed after fibrinolytic therapy. (A) The right atrium (ra) is free of thromboembolic masses. A Chiari network (arrowheads) is present. rv= right ventricle. (B) The thromboemboli previously visible in the right pulmonary artery (rpa) have disappeared. rpa = right pulmonary artery, svc = superior vena cava, ao = aorta, mpa = main pulmonary artery.
 Proano M, Frye RL, Johnson CM, Taliercio CP. Successful treatment of pulmonary embolism and associated mobile right atrial thrombus with use of a central thrombolytic infusion. Mayo Clin Proc 1988; 63: 1181-5.
 Farfel Z, Shechter M, Vered Z, Rath S, Goor D, Gafni J. Review of echocardiographically diagnosed right heart entrapment of pulmonary emboli-in-transit with emphasis on management. Am Heart J 1987; 113:171-8.
 Pavan D, Nicolosi GL, Lestuzzi C, Burelli C, Zardo F, Zanuttini D. Normalization of variables of left ventricular function in patients with alcoholic cardiomyopathy after cessation of excessive alcohol intake: an echocardiographic study. Eur Heart J 1987; 8: 457-63.
KEY WORDS: transoesophageal echocardiography, right atrial masses, pulmonary artery thromboemboli, cardiomyopathies.