Acute thrombus formation as a complication of right ventricular biopsy

While using echocardiography to guide endomyocardial biopsy (EMB), the authors have identified acute intracardiac thrombus formation related to the procedure, a hitherto unreported complication. The aims of this study were to identify the procedural details and characteristics of patients who developed this complication between June 2008 and April 2009 and to describe their outcomes and management.

In total, 415 right ventricular biopsies were performed during this period. Of these, 189 were echocardiographically guided, and the medical records of these patients were reviewed retrospectively.

There were eight cases of acute right-sided intracardiac thrombus formation in seven patients (about 4% of the echocardiographically guided group) at the time of biopsy. The indications for EMB were heart transplant surveillance in six patients and suspected cardiac amyloidosis in one patient. Three cases were performed via a transjugular approach and four via a femoral approach. Four patients had histories of prior thromboses, and one patient had a defined clotting diathesis. Management included either immediate thrombus aspiration or postprocedural anticoagulation. There were no overt occurrences of pulmonary thromboembolism.

Acute thrombus formation is a complication of EMB. If this complication is unrecognized, and therefore untreated, pulmonary thromboembolism may result. This may have important clinical implications in patients undergoing routine repeated surveillance EMB after cardiac transplantation. The authors recommend performing transthoracic echocardiography during EMB, particularly in patients with histories of thrombosis, because this group of patients may be at increased risk for procedural thrombosis, and procedural echocardiography permits early recognition and treatment of this complication.