Evrin Dağtekin, Çağdaş AKGÜLLÜ, Ufuk Eryılmaz

Pulmoner Artere Doğru Seyri Sırasında Heparin ile Tedavi Edilen Serbest Yüzen Dev Sağ Atriyal Pıhtı

Sağ atriyumda serbest yüzen pıhtı, yüksek mortaliteyle seyreder. Trombolitik tedavi ve cerrahi trombektomi önerilse de, yönetimi halen tartışma konusudur. Bir ay önce inme öyküsü olan 78 yaşında kadın hasta acil servise çarpıntı şikayetiyle başvurdu. Transtorasik ekokardiyografi yle sağ atriyum içerisinde serbest yüzen büyük bir pıhtı saptandı. Trombolitik tedavi açısından kontrendikasyonları olması sebebiyle 5000 IU intravenöz anfraksiyone heparin bolus yapılarak cerrahi trombektomi hazırlıklarına başlandı. Heparin bolusundan yaklaşık 90 dakika sonra pıhtıyı transtorasik ekokardiyografi yle tekrar kontrol ettiğimizde, artık yerinde olmadığını gördük fakat sağ kalp boşluklarında hafi f bir genişleme vardı. Hasta hemodinamik olarak stabildi. Kontrastlı toraks bilgisayarlı tomografi tetkikinde subsegmental pulmoner arter dallarında çok sayıda küçük dolum defektleri izlendi. Ameliyat iptal edildi ve Doppler ultrasonografi de sol alt ekstremitede derin ven trombozu saptandı. Yetmiş iki saatlik heparin infüzyonunu takiben warfarin başlandı. Hastanede yatış süresince herhangi bir komplikasyon gelişmedi. Hasta takip eden üç ay boyunca stabildi. Sağ atriyal serbest yüzen pıhtısı olan bu hastada unfraksiyone heparinin kısmen işe yaraması, pıhtının taze, organize olmamış ve kırılgan yapısından kaynaklanıyor olabilir. Sağ atriyal serbest yüzen pıhtısı olan hastalarda, özellikle trombolitik tedavi kontrendikeyse ve cerrahi mortalite yüksekse, cerrahi öncesinde anfraksiyone heparin tedavisine başlamak ve birkaç saat sonra pıhtıyı kontrol etmek alternatif olabilir.

Anahtar Kelimeler:

Sağ atriyum, trombüs, derin ven trombozu, anfraksiyone heparin.

A Free Floating Right Atrial Giant Thrombus Treated by Heparin on the Road to Pulmonary Arteries

Free fl oating right atrial thrombi are associated with high mortality. Although trombolysis and surgical trombectomy are recommended, their management is still the subject of debate. A 78 year old woman with a history of stroke a month ago, presented to the emergency department with palpitation. Transthoracic echocardiography revealed a large free-fl oating right atrial thrombus. After intravenous bolus of 5000 IU unfractional heparin she was prepared for cardiac surgery because of contraindications for trombolytic therapy. About 90 minutes after unfractional heparininfusion, we decided to check the thrombus, and realised that it was not there anymore, but there was a slight enlargement in right cardiac chambers. Patient was hemodynamically stabil. Contrast enhanced computerized tomography demonstrated multiple small fi lling defects in the subsegmental branches of pulmonary tree. Surgery was cancelled and Doppler ultrasonography revealed deep venous thrombosis in the left lower limb. After 72 hours of continuous unfractional heparin infusion, warfarin was started. During the hospitalization there was not any complication. Patient was stabil for the following three months. This is a report of free fl oating right atrial trombus origined from deep lower extremity veins and treated by unfractional heparin without any clinical deterioration. In this particular case we think that unfractional heparin might have partly worked because of fresh, unorganised and fragil thrombus. In patients with right atrial free fl oating thrombus, especially when thrombolytic therapy is contraindicated and surgical mortality is high, it may be an alternative to start unfractional heparin and check the thrombus after several hours before the surgery.

Keywords:

Right atrium, thrombus, deep vein thrombosis, unfractioned heparin.,

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