A Case of a Massive Right Atrial Thrombus Removal Under Transesophageal Echocardiographic Guidance.

Background: With the advent of catheter guided interventions, practitioners have added another tool alongside chemical lysis and surgical removal to reduce the clot burden of patients with large emboli and thrombi. Due to comorbid conditions, many patients are poor candidates for surgical or chemical clot treatment but may present optimally for catheter-based thromboembolectomy. In this case, we highlight the benefits of mechanical thrombectomy with transesophageal echocardiographic guidance to reduce the clot burden of a patient who would otherwise be considered a poor candidate for surgical or chemical treatment.

Case presentation: This case follows a 78-year-old man with a past medical history significant for persistent atrial fibrillation, type 2 diabetes, hypertension, hyperlipidemia, coronary artery disease, cardiomyopathy status post biventricular implantable cardioverter-defibrillator, left atrial appendage exclusion device, and a recent deep vein thrombosis. The patient was taking apixaban and was found to have a large, mobile, right atrial thrombus on a transthoracic echocardiograpic evaluation for a routine sepsis workup. The patient underwent an emergency thrombectomy due to the high risk of thrombus embolization. Due to the large size of the thrombus and complexity of the case, an intra-operative inferior vena cava filter was placed to prevent shower embolization of the thrombus during evacuation. Under guidance from the transesophageal echocardiography, the thrombus was successfully removed using a mechanical thrombectomy device.

Conclusion: In an aging population with significant cardiac or hematological comorbidities, some patients who develop right atrial thrombi may be considered poor candidates for an open thrombectomy or chemical thrombolysis. With the development of catheter based mechanical thrombectomy interventions, patients with relative contraindications to traditional methods may benefit from newer technology, especially if the technique allows for accurate visualization of the thrombus via transesophageal echocardiography.