Anticoagulation with heparin followed by apixaban resulted in complete resolution of an incidental isolated right ventricular thrombus at 6 weeks in a 63-year-old female.
Case Report (n=1)
Isolated right ventricular thrombus without pulmonary embolism is a rare clinical entity that can be successfully managed with direct oral anticoagulants such as apixaban.
Abstract Introduction Right ventricular thrombus (RVT) is significantly less common than left ventricular thrombus (LVT). RVT is mainly detected in patients undergoing evaluation for pulmonary embolism (PE). Isolated RVT without concurrent PE is considered rare. We highlight a case of incidental isolated RVT in the absence of PE. Case Presentation A 63-year-old female patient with a medical history of chronic obstructive pulmonary disease (COPD), diastolic heart failure, and multiple hospitalizations for respiratory failure, presented to the emergency department (ED) with dyspnea. Her vital signs were stable except for a respiratory rate of 22 breaths per minute and hypoxia which improved to SpO2 98% on 3L/min nasal cannula. Laboratory results were unremarkable except for a brain natriuretic peptide of 963 pg/ml. Venous blood gas showed PH 7.25, pCO2 54 mmHg. Her chest X-ray showed right pleural effusion. Her clinical condition eventually deteriorated, and she was intubated and admitted to our critical care service for further management of her heart failure and COPD exacerbation. Computerized tomography (CT) pulmonary angiogram protocol was obtained in the ED, which was negative for PE, but showed a 21.4 mm x 18.42 mm filling defect in the right ventricle (RV). Transthoracic echocardiogram (TTE) confirmed a 2x2 cm large thrombus in the RV apex. These findings were not evident on prior CT and TTE obtained seven and thirteen months earlier. Following multidisciplinary review including cardiology and interventional radiology, AngioVac was deemed unsuitable because of the thrombus’s location. She was started on heparin infusion and eventually switched to apixaban. Following clinical improvement, she was extubated and discharged. She remained on apixaban and a TTE obtained six weeks later showed complete resolution of her RVT. Discussion RVT is a rare clinical finding, and is estimated to be in 2-6% of patients diagnosed with PE. Most studies focus on RVT in the context of PE, leaving isolated RVT poorly understood and potentially underdiagnosed. This may be due to limitations in standard imaging techniques and a greater diagnostic emphasis on LVT or RVT associated with PE. When RVT is detected incidentally, prompt initiation of anticoagulation is recommended, with a multidisciplinary approach considered in cases with high thrombus burden or complex anatomy. Some studies suggest that isolated RVT has a more favorable prognosis and lower mortality than RVT associated with PE, as was seen in our case presentation; however, further research is needed to establish guidelines for screening, treatment, and long-term follow-up. This abstract is funded by: None
Freihat et al. (Fri,) conducted a case report in Right ventricular thrombus without pulmonary embolism (n=1). Heparin infusion followed by apixaban was evaluated on Resolution of right ventricular thrombus. Anticoagulation with heparin followed by apixaban resulted in complete resolution of an incidental isolated right ventricular thrombus at 6 weeks in a 63-year-old female.