Real-time detection of migratory thrombi by transesophageal echocardiography in a patient undergoing thrombectomy

We report a 44-year-old male patient who sustained a right atrial (RA) thrombosis with evolvement into right pulmonary artery embolism in consequence of placement of a temporary pacing lead and was successfully treated with surgical thrombectomy under the guidance of perioperative transesophageal echocardiography (TEE). Because of intermittent complete atrioventricular block he therefore underwent implantation of a transvenous temporary pacing. On the ensuing day a large mass was incidentally found echographically in the RA suggestive of a large thrombus. Immediate surgical removal of the mass was indicated. During the emergent open-heart surgery the mass in RA dehiscenced with fragments migrating to the right main pulmonary artery, and exploration of both the RA and right pulmonary artery was done. This migratory mass, which proved to be a fresh thrombus, was surgically removed. The cardiopulmonary bypass was then terminated and the spontaneous contraction of heart was resumed. However, another mass lesion was found in RA on the TEE screen just following the removal of the problematic transvenous pacing wire. The right atrium was thus re-opened immediately and the second thrombus was cleared. Over the on-going surgical course no further abnormal echogenic objects were visible in the cardiac chambers. It is perceivable that transvenous pacing might cause thrombois or dislodgement and dehiscence of thrombi already in existence in the cardiac chamber. Careful and continuous intraoperative surveillance with echocardiography over a patient who is undergoing cardiac embolectomy is quite important in detecting thrombus escape and residual thrombi during surgery.