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Right Ventricular Thrombus in Transit or Just a Right Heart Thrombus? Eppur si Muove!

      We read with interest the Letter to the Editor regarding our recent publication in the Journal (
      • Carrizales-Sepúlveda EF
      • Mejía-Melara Q
      • González-Dávila SE
      • et al.
      Right ventricular thrombus in transit in a patient with COVID-19.
      ). First, we would like to thank the authors for their insightful analysis and comments on our work. In our article, we describe the case of a 62-year-old man that presented to our unit with COVID-19 and respiratory distress and required invasive mechanical ventilation. During his hospital stay, he experienced sudden hemodynamic instability that required escalating doses of vasopressors. When we evaluated the patient with the use of point-of-care cardiac ultrasound (POCCUS), we found a severely dilated right ventricle (RV) with systolic D-shape suggestive of acute RV pressure overload and a McConnell's sign, which is highly specific for a pulmonary embolism (PE). Along with this, we caught a thin, worm-like, highly mobile mass, suggestive of a thrombus that was clearly moving toward the main pulmonary artery. This is shown in Video 1 and Figure 1 of our article (
      • Carrizales-Sepúlveda EF
      • Mejía-Melara Q
      • González-Dávila SE
      • et al.
      Right ventricular thrombus in transit in a patient with COVID-19.
      ). With this finding, and in the context of a patient with hemodynamic instability and echocardiographic data of acute RV pressure overload, we made a diagnosis of a massive (high-risk) PE and decided to give intravenous thrombolytic therapy as recommended in the guidelines, which led to a rapid improvement in hemodynamic status and progressive decrease in vasopressor dose (
      • Konstantinides SV
      • Meyer G
      • Becattini C
      • et al.
      2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS).
      ).
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      References

        • Carrizales-Sepúlveda EF
        • Mejía-Melara Q
        • González-Dávila SE
        • et al.
        Right ventricular thrombus in transit in a patient with COVID-19.
        J Emerg Med. 2022; 62: 566-568
        • Konstantinides SV
        • Meyer G
        • Becattini C
        • 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
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      1. The European Cooperative Study on the clinical significance of right heart thrombi. European Working Group on Echocardiography.
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      Linked Article

      • Documentation of Deep Vein Thrombosis Should Be a Requirement for Reporting Embolus in Transit
        Journal of Emergency MedicineVol. 63Issue 4
        • Preview
          In their case report, Carrizales-Sepulveda et al. seem to equate the presence of a right ventricular thrombus with an embolus in transit from the deep veins to the pulmonary arterial circulation (1). According to one definition, however, “Right heart thrombi in transit represent emboli from the deep veins that are temporarily lodged in the right atrium or ventricle in patients with pulmonary embolism” (2). Likewise, in their review of right heart thrombi in transit, Rivera et al. characterized right heart emboli-in-transit as being “frequently associated [with] deep vein thrombosis (DVT) of lower limbs, and rarely [with] a heart condition” (3).
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