Early surgical treatment in patients with pulmonary embolism and thrombus-in-transit

Floating right heart thrombi (RHT) are in transit from the legs to the pulmonary arteries and thus are a severe form of venous thromboembolism (VTE), with a high early mortality rate without treatment. There is a lack of evidence-based recommendations for its management. The objective of this study is to describe our experience in the surgical management of thrombus-in-transit and pulmonary embolism (PE) in a tertiary hospital.

We recruited four patients with thrombus-in-transit and PE treated with early surgical embolectomy and anticoagulation. Epidemiologic, laboratory, imaging and clinical data of the thromboembolic episode and the subsequent course were collected.

The sample included 3 males and 1 female, with a mean age of 49.7. The most frequent initial symptoms were dyspnea, syncope, chest pain and signs of deep vein thrombosis (DVT). Transthoracic echocardiogram (TTE) found the thrombus-in-transit in all the cases. The inicial treatment was unfractionated heparin (UFH) and urgent right atriectomy and manual removal of the thrombi. Three patients needed perioperative infusion of vasopressor drugs. All patients had right heart dysfunction at the time of diagnosis. The mean scoring in the Pulmonary Embolism Severity Index (PESI) was 90. All patients survived after 30 days of follow-up.

Early surgical embolectomy of thrombus-in-transit is an effective option of management in selected patients, although the current evidence to support this approach is not definitive.