(1157) Every Clot Was Once in Transit: Time to Revisit Reflexive Advanced Reperfusion Strategy

Introduction: Right heart thrombus (RHT) portends a threefold increase in short-term mortality in patients with acute pulmonary embolism. Historical data has shown excess mortality with anticoagulation alone, thus treatment strategies have focused on advanced reperfusion therapy. However, there remains a knowledge gap for such an approach resulting in wide practice variation. Given uncertainty around risk stratification and optimal treatment, characterization of the clinical phenotypes remains of utmost importance.

Description: A convenience sample of eight patients with RHT admitted to our hospital from 2020-2024 were evaluated. Ages ranged from 35 to 91 years; five were female. Five presented with dyspnea, two with syncope and one with stroke. All had large clot burden involving central and peripheral pulmonary arteries on CT angiography and echocardiographic right atrial mobile thrombus. DVT was noted in five subjects. Two patients had patent foramen ovale (PFO). Vital signs on presentation, reported as median (IQR), were as follows: HR 100 (15.5), SBP 122 (26.5) and SPO2 96 (2.5). Initial BOVA, PESI, and NEWS scores ranged from 2-6, 42-156 and 2-7 respectively. Six subjects had RV dysfunction with average RVSP 30 mmHg. Seven patients were anticoagulated with heparin; one was not due to stroke. Two also received systemic thrombolysis, one underwent suction thrombectomy followed by AngioVac with subsequent recovery, one had AngioVac and died intraoperatively, and one had surgical embolectomy with good recovery. Both patients with a PFO underwent embolectomy (one surgical and one AngioVac). The four patients treated with anticoagulation and/or systemic thrombolysis all survived to discharge. The patient with PE and stroke was transitioned to comfort measures.

Discussion: Patients with RHT exhibit a wide range of clinical phenotypes and hemodynamic profiles. Mortality is primarily driven by hemodynamics, cardiopulmonary reserve and RV dysfunction. Existing data does not support upfront systemic thrombolysis in the absence of shock, whereas for percutaneous and surgical embolectomy, there is a state of equipoise due to small studies prone to type II error. Further research is needed for precise risk stratification and prudent patient selection for advanced therapies.