Embolus in Transit
A patient who presented with recurrent syncopal episodes was discovered to have a right-sided heart mass, which was revealed as an embolus in transit resulting in a lethal pulmonary embolic event. The initial focus of etiology on tumor rather than thrombus was misleading. A higher index of suspicion of thrombus in right heart mass may help future patients receive more directed therapy.
Cardiac masses can include tumor, vegetation, thrombus, or artifact. Right-sided heart masses are most often renal cell or uterine carcinoma, atrial or ventricular myxoma, or migrant thrombi. Such migrant thrombi, often termed emboli in transit, have subtle distinguishing characteristics that are essential in consideration of treatment modality.
Atrial fibrillation or heart failure can often lead to left atrial or left ventricular dilation and predisposition to thrombus formation. Formation of thrombi in the right heart is much less frequent. These thrombi are more often embolized venous thrombi that have become entrapped in the valves and trabeculations of the right atrium and ventricle, thus appearing as a cardiac mass on an echocardiogram. The mass is often pleomorphic and may demonstrate mobility during the imaging studies.
Acute pulmonary embolus often arises from lower-extremity deep vein thrombosis and may be unsuspected clinically, delaying treatment. Pulmonary emboli result in 50,000 to 100,000 preventable deaths yearly. Indeed, the mortality rate for emboli in transit, specifically, may reach 50%. It is estimated that 33% of emboli in transit initially detected by echocardiography will proceed to full pulmonary embolism within 24 hours. In cases of pulmonary embolism with rapid deterioration and death, it is common to find large emboli obstructing the main pulmonary artery or the bifurcation of the pulmonary artery.
A patient who presented with recurrent syncopal episodes was discovered to have a right-sided heart mass, which was revealed as an embolus in transit resulting in a lethal pulmonary embolic event. The initial focus of etiology on tumor rather than thrombus was misleading. A higher index of suspicion of thrombus in right heart mass may help future patients receive more directed therapy.
Cardiac masses can include tumor, vegetation, thrombus, or artifact. Right-sided heart masses are most often renal cell or uterine carcinoma, atrial or ventricular myxoma, or migrant thrombi. Such migrant thrombi, often termed emboli in transit, have subtle distinguishing characteristics that are essential in consideration of treatment modality.
Atrial fibrillation or heart failure can often lead to left atrial or left ventricular dilation and predisposition to thrombus formation. Formation of thrombi in the right heart is much less frequent. These thrombi are more often embolized venous thrombi that have become entrapped in the valves and trabeculations of the right atrium and ventricle, thus appearing as a cardiac mass on an echocardiogram. The mass is often pleomorphic and may demonstrate mobility during the imaging studies.
Acute pulmonary embolus often arises from lower-extremity deep vein thrombosis and may be unsuspected clinically, delaying treatment. Pulmonary emboli result in 50,000 to 100,000 preventable deaths yearly. Indeed, the mortality rate for emboli in transit, specifically, may reach 50%. It is estimated that 33% of emboli in transit initially detected by echocardiography will proceed to full pulmonary embolism within 24 hours. In cases of pulmonary embolism with rapid deterioration and death, it is common to find large emboli obstructing the main pulmonary artery or the bifurcation of the pulmonary artery.