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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 125-128

Successful outcome with outpatient acenocoumarol therapy for echocardiographically visible pulmonary thrombus


1 Department of Pulmonary Medicine, Apollo Speciality Hospital, Nellore, Andhra Pradesh, India
2 Department of Cardiology, Kasturba Medical College, Mangalore, Karnataka, India

Date of Submission17-Jul-2020
Date of Acceptance23-Dec-2020
Date of Web Publication17-Jul-2021

Correspondence Address:
Karanam Gowrinath
Consultant, Department of Pulmonary Medicine, Apollo Speciality Hospital, Pinakininagar, Nellore 524 004, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCSR.JCSR_60_20

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  Abstract 


Visualisation of thrombus in the main pulmonary artery through two-dimensional transthoracic echocardiography (TTE) without cardiovascular instability is rare. We report a unique case of echocardiographically diagnosed acute pulmonary embolism (PE) in an ambulatory patient with concomitant cor pulmonale secondary to idiopathic interstitial lung disease. The mobile thrombus was first visualised at the junction of bifurcation of the pulmonary trunk with left pulmonary artery through routine two-dimensional TTE. Two days later, the contrast-enhanced computerised tomographic scan of the chest showed the thrombus to be in the distal portion of the right pulmonary artery. Complete resolution of pulmonary thrombus was achieved with a 3-month course of outpatient oral anticoagulation treatment with acenocoumarol without recurrence of PE during the 1-year follow-up.

Keywords: Acenocoumarol, cor pulmonale, echocardiography, interstitial lung disease, pulmonary embolism


How to cite this article:
Gowrinath K, Kamath K P. Successful outcome with outpatient acenocoumarol therapy for echocardiographically visible pulmonary thrombus. J Clin Sci Res 2021;10:125-8

How to cite this URL:
Gowrinath K, Kamath K P. Successful outcome with outpatient acenocoumarol therapy for echocardiographically visible pulmonary thrombus. J Clin Sci Res [serial online] 2021 [cited 2021 Aug 3];10:125-8. Available from: https://www.jcsr.co.in/text.asp?2021/10/2/125/321701




  Introduction Top


Two-dimensional transthoracic echocardiography (TTE) can assess ventricular size and function, regional wall motion, valvular dysfunction, intracardiac shunting, haemodynamic measurement of left and right cardiac chamber pressures and in addition can visualise thrombi within heart chambers.[1] Visualisation of thrombus through two-dimensional TTE in the right heart chambers or in the main pulmonary artery is rare and was documented recently in 2.5% of cases.[2] Free-floating thrombus in transit in the right heart is uncommon, and most of the affected persons have acute and severe symptoms with haemodynamic instability.[3] Right heart thrombus is an independent predictor of death in acute pulmonary embolism (PE) with higher mortality compared to those without them.[4] PE is difficult to suspect clinically without acute symptoms in an ambulatory patient with concomitant lung disease and chronic cor pulmonale.


  Case Report Top


A 62-year-old woman complained of reduced exercise tolerance and tiredness of 10-day duration. She has been under regular follow-up for idiopathic interstitial lung disease with cor pulmonale for the past 6 months. Physical examination showed digital clubbing, engorged neck veins but no cyanosis. Her blood pressure was 130/86 mmHg and resting room air oxygen saturation was 94%. Clinical examination of the respiratory system showed bilateral crackles and of the cardiovascular system revealed loud second heart sound at the pulmonary area. Laboratory reports were not significant. A chest X-ray [Figure 1] showed cardiomegaly with bilateral interstitial opacities. A 12-lead electrocardiogram revealed P-pulmonale with right ventricular hypertrophy. Routine two-dimensional TTE [Figure 2] showed a mobile thrombus (2.1 cm × 1.2 cm) at the junction of bifurcation of the main pulmonary trunk with left pulmonary artery. Severe pulmonary arterial hypertension (PAH) with enlargement/hypertrophy of the right heart chambers were additional pre-existing findings. Doppler's ultrasound study of lower limbs was normal. A contrast-enhanced computerised tomography (CECT) of the chest done 2 days later showed filling defect in the distal portion of the right pulmonary artery [Figure 3]. The diagnosis of acute PE was made. As the patient was haemodynamically stable and ambulatory, outpatient oral anticoagulation was started with once daily acenocoumarol. The dosage of acenocoumarol was adjusted to maintain international normalised ratio of 2–3. The patient improved clinically, and follow-up CECT of the chest after 1 month showed complete resolution of thrombus. A 3-month course of oral anticoagulation therapy was given, and the patient remained stable during 1-year follow-up without recurrence of PE.
Figure 1: Chest X-ray (postero-anterior view) showing cardiomegaly and bilateral reticulonodular opacities

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Figure 2: Two-dimensional transthoracic echocardiography showing 2.1 cm × 1.2 cm size thrombus (white arrow) at the junction of bifurcation of the main pulmonary trunk with left main branch of pulmonary artery

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Figure 3: Contrast-enhanced computed tomography scan of the chest showing a filling defect (arrow) in the distal portion of the right pulmonary artery

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  Discussion Top


PE is considered as massive when there is hypotension or submassive if normotensive along with right ventricular dysfunction and stable if normotensive without right ventricular dysfunction.[5] Our patient had normal blood pressure with pre-existing cor pulmonale. Severe PAH, severe tricuspid regurgitation, low cardiac output and prominent Eustachian valves may act as pre-disposing factors of thrombus formation in the right heart chambers.[6] Our patient had severe PAH and tricuspid regurgitation as pre-disposing factors of thrombus formation. Two-dimensional TTE cannot visualise the entire pulmonary trunk and its main branches but can demonstrate indirect signs of massive or submassive PE.[7] If pulmonary artery is already dilated, the main pulmonary trunk and its two main branches are visualised well and any thrombus in this area is readily detected.[8] Our patient had severe PAH with enlarged pulmonary artery facilitating detection of thrombus at the junction of bifurcation of the main pulmonary artery by the two-dimensional TTE. The mobile thrombus migrated to the distal portion of the right pulmonary artery within 2 days as shown by the CECT of chest. TTE as a screening test has 50%–60% sensitivity for detection of right heart thrombus compared to transoesophageal echocardiography which has higher sensitivity of 80% and specificity of 100%.[9] Because of its low sensitivity, TTE is not recommended as a primary diagnostic test of suspected PE unless the patient is acutely ill with cardiovascular instability.[10] In our case, TTE was done to evaluate decreased exercise tolerance and detection of pulmonary thrombus was incidental. Concomitant deep vein thrombosis was associated with right heart thrombi in about 38% of cases,[11] but in our case, deep vein thrombosis was not demonstrable.

Surgical embolectomy, thrombolysis and anticoagulation are the treatment options for right heart thrombi, but none of them have been standardised. The treatment of PE with right heart thrombi must be individualised based on the risks and therapeutic response. Free-floating right heart thrombus was considered as one of the echocardiographic markers of risk of death or recurrent PE requiring thrombolysis or embolectomy.[12] A 15-year study of right heart thrombi with acute PE showed no difference in the treatment outcome between reperfusion (thrombolysis and embolectomy) and anticoagulant therapy in terms of mortality, bleeding or recurrence.[12] In another study, 40% of right heart thrombi on anticoagulation treatment had to be switched to thrombolysis or surgical embolectomy due to acute clinical deterioration.[13] Recent guidelines on management of acute PE[14] recommended oral anticoagulation with non-vitamin K antagonists such as dabigatran, rivaroxaban or edoxaban as they can be administered at a fixed dose without routine laboratory monitoring and have less drug interactions compared to vitamin K antagonists. In India, the newer non-vitamin K antagonist oral anticoagulants are still not widely available and are comparatively expensive. We used acenocoumarol, a low-cost and widely available oral Vitamin K antagonist because of its rapid onset of action, long-term safety with comparable efficacy and better stability of anticoagulant effect than warfarin.[15],[16] In our case, the mobile pulmonary thrombus was probably not large enough to cause haemodynamic instability and the successful treatment outcome of pulmonary thrombus with oral acenocoumarol is significant and we are not aware of previous similar report in English literature.

To conclude, the severity of PE is difficult to determine when blood pressure is normal with pre-existing cor pulmonale. Severe PAH with enlarged pulmonary artery may improve visibility of routine TTE and help to locate the pulmonary thrombus. The outpatient oral anticoagulation therapy with acenocoumarol under regular monitoring is effective in selected cases of acute PE without cardiovascular instability.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Patel B, Shah M, Garg L, Agarwal M, Martinez M, Dusaj R. Trends in the use of echocardiography in pulmonary embolism. Medicine (Baltimore) 2018;97:e12104.  Back to cited text no. 1
    
2.
Bikdeli B, Lobo JL, Jiménez D, Green P, Fernández-Capitán C, Bura-Riviere A, et al. Early use of echocardiography in patients with acute pulmonary embolism: Findings from the RIETE Registry. J Am Heart Assoc 2018;7:e009042.  Back to cited text no. 2
    
3.
Torbicki A, Galie N, Covuzzoli A, Rossi E, De Rosa M, Goldhaber SZ. ICOPER study group right heart thrombi in pulmonary embolism: Results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol 2003;41:2245-51.  Back to cited text no. 3
    
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Barrios D, Rosa-Salazar V, Jiménez D, Morillo R, Muriel A, Del Toro J, et al. Right heart thrombi in pulmonary embolism. Eur Respir J 2016;48:1377-85.  Back to cited text no. 4
    
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Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016;149:315-52.  Back to cited text no. 5
    
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Agarwal R, Aggarwal AN, Gupta D. Is right heart thromboemboli another indication for thrombolysis? Intern Med J 2007;37:333-5.  Back to cited text no. 6
    
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Patel JJ, Chandrasekaran K, Maniet AR, Ross JJ Jr., Weiss RL, Guidotti JA. Impact of the incidental diagnosis of clinically unsuspected central pulmonary artery thromboembolism in treatment of critically ill patients. Chest 1994;105:986-90.  Back to cited text no. 7
    
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Apaslan M, Akgun G, Doven O, Oral D. Thrombus in the main pulmonary artery of a patient with thromoangiitits obliterance: Observation by transthoracic echocardiography. Eur J Echocardiography 2001;2:139-40.  Back to cited text no. 8
    
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Schwartzband AZ, Tunick PA, Rosenzweig BP, Kronzon I. The role of transoesophageal echocardiography in the diagnosis and treatment of right atrial thrombi. J Am Soc Echocardiogr 1999;12:64-68.  Back to cited text no. 9
    
10.
Saric M, Armour AC, Arnaout MS, Chaudhry FA, Grimm RA, Kronzon I, et al. Guidelines for the use of echocardiography in the evaluation of a cardiac source of embolism. J Am Soc Echocardiogr 2016;29:1-42.  Back to cited text no. 10
    
11.
Mohan B, Chhabra ST, Gulati A, Mohan Mittal C, Mohan G, Tandon R, et al. Clinical and echocardiographic diagnosis, follow up and management of right-sided cardiac thrombi. Indian Heart J 2013;65:529-35.  Back to cited text no. 11
    
12.
Goldhaber SZ. Echocardiography in the management of pulmonary embolism. Ann Intern Med 2002;136:691-700.  Back to cited text no. 12
    
13.
Barrios D, Chavant J, Jimenez D, Berlotti L, Rosa-Salazar V, Muriel A, et al. Treatment of right heart thrombi associated with acute pulmonary embolism. Am J Med 2017;130:588-95.  Back to cited text no. 13
    
14.
Athappan G, Sengodan P, Chacko P, Gandhi S. Comparative efficacy of different modalities for treatment of right heart thrombi in transit: A pooled analysis. Vasc Med 2015;20:131-8.  Back to cited text no. 14
    
15.
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2020;41:543-603.  Back to cited text no. 15
    
16.
Trailokya A, Hiremath JS, Sawhney J, Mishra YK, Kanhere V, Srinivasa R, et al. Acenocoumarol: A review of anticoagulant efficacy and safety. J Assoc Physicians India 2016;64:88-93.  Back to cited text no. 16
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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