Abnormal Cardiac Ultrasound Imaging in a Patient With Sudden Neurologic Deficit

Abstract

A 66-year-old woman admitted for encephalitis and focal status epilepticus demonstrated a sudden right facial droop and lethargy 2 weeks into hospitalization. Head and neck CT scan angiography (CTA) showed unremarkable results except for incidental bilateral pulmonary emboli (PE), subsequently confirmed on chest CTA (Fig 1). Despite the clot burden documented on CTA and except for borderline tachycardia (heart rate, 103 beats/min), the remaining vital signs were in the normal range, including a normal oxygen saturation on room air. A cardiac point-of-care ultrasonography (POCUS) examination was performed (Video 1) at the time of admission to the ICU.Question: Based on the POCUS video and the additional patient data, which finding on the video should lead to urgent interventions?Answer: A large right heart thrombus-in-transit.Videos 1 and 2 show a mobile right heart thrombus.DiscussionPOCUS findings included a mobile right heart mass, a normal right atrial size, and a grossly normal right ventricular size and function (Video 1). POCUS findings were confirmed by a formal transthoracic echocardiogram that showed a mobile 4 × 2.6-cm right heart mass, normal estimated right-heart pressures, and preserved right ventricular function based on tricuspid annular plane systolic excursion assessment (Fig 2, Video 2). DVT also was identified in the left lower extremity. Progressive thrombocytopenia had been documented (32,000/μL), and argatroban was initiated. Platelet factor 4 immunoassay results were indeterminate. Given the patient’s history of left frontal focal seizures and the negative brain imaging results, the neurology service suspected focal seizure activity to be the reason for the acute neurologic changes. A bubble study was not pursued given the negative brain imaging results and the lack of evidence to suggest an acute stroke after formal neurologic evaluation. The patient’s acute deficits resolved within 24 h of ICU admission.Figure 2Transthoracic echocardiogram apical four-chamber view showing an echo-dense material (arrow) representing a thrombus in the right atrium crossing the tricuspid valve into the right ventricle.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Given the high mortality risk for thrombus-in-transit,1Barrios D. Rosa-Salazar V. Morillo R. et al.Prognostic significance of right heart thrombi in patients with acute symptomatic pulmonary embolism: systematic review and meta-analysis.Chest. 2017; 151: 409-416Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar thrombectomy and thrombolytics were considered in this patient. Penumbra Indigo CAT8 (Penumbra, Inc.) suction thrombectomy was pursued based on local availability. This required dual right femoral vein access for the 8.5-F Penumbra sheath and the intracardiac echocardiography (ICE) probe. ICE was favored over transesophageal echocardiography for its ability to visualize the right heart directly under conscious sedation. ICE largely has replaced transesophageal echocardiography for procedures such as atrial septal defect closure and catheter ablation of cardiac arrhythmias. Benefits include excellent patient tolerance, reduction of fluoroscopy time, and lack of need for general anesthesia.2Enriquez A. Saenz L.C. Rosso R. et al.Use of intracardiac echocardiography in interventional cardiology: working with the anatomy rather than fighting it.Circulation. 2018; 137: 2278-2294Crossref PubMed Scopus (112) Google Scholar In this patient, ICE provided optimal images of the thrombus-in-transit (Fig 3A). A snare was used to hold and break the clot while applying continuous suction, and the clot was aspirated successfully (Fig 3B, 3C, Video 3). Because the patient remained asymptomatic and was fully anticoagulated, no PE aspiration was performed, and CTA was not repeated.Figure 3A, Intracardiac echocardiogram with a short axis view at the level of the AV showing a large thrombus in the RA crossing the tricuspid valve into the RV (arrow). B, Penumbra suction embolectomy catheter in the right atrium (arrow). C, Successful suction thrombectomy with minimal residual clot. AV = aortic valve; RA = right atrium; RV = right ventricle; RVOT = right ventricle outflow tract.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Optimal treatment for right heart thrombi is not well defined.1Barrios D. Rosa-Salazar V. Morillo R. et al.Prognostic significance of right heart thrombi in patients with acute symptomatic pulmonary embolism: systematic review and meta-analysis.Chest. 2017; 151: 409-416Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar,3Galeano-Valle F. Demelo-Rodriguez P. Garcia-Fernandez-Bravo I. et al.Early surgical treatment in patients with pulmonary embolism and thrombus-in-transit.J Thorac Dis. 2018; 10: 2338-2345Crossref PubMed Scopus (2) Google Scholar Penumbra Indigo recently was studied4Sista A.K. Horowitz J.M. Tapson V.F. et al.Indigo aspiration system for treatment of pulmonary embolism.JACC Cardiovasc Interv. 2021; 14: 319-329Crossref PubMed Scopus (44) Google Scholar and approved for PE aspiration, but to our knowledge, this is its first reported use for aspiration of a thrombus-in-transit.5Biney I. Turner J.F. McKeown P. Soto F.J. Akhtar Y. Acute pulmonary embolism associated with a mobile right atrial thrombus managed by suction thrombectomy [abstract].Chest. 2019; 156: A911Abstract Full Text Full Text PDF Google Scholar In this patient, the small sheath size was ideal given the patient’s higher bleeding risk. However, for large in-transit clots, additional tools may be needed and clot fragments could migrate. The newer Penumbra Indigo CAT12’s larger 12-F lumen could be an additional alternative for such patients. The AngioVac (a 26-F sheath; AngioDynamics, Inc) and FlowTriever (a 22-F sheath; Inari Medical, Inc) also are approved6Rali P.M. Criner G.J. Submassive pulmonary embolism.Am J Respir Crit Care Med. 2018; 198: 588-598Crossref PubMed Scopus (33) Google Scholar,7Giri J. Sista A.K. Weinberg I. et al.Interventional therapies for acute pulmonary embolism: current status and principles for the development of novel evidence: a scientific statement from the American Heart Association.Circulation. 2019; 140: e774-e801Crossref PubMed Scopus (125) Google Scholar for suction thrombectomy in PE (and right-heart thrombectomy for AngioVac), but were not available to us at the time of the patient’s presentation. Notably, they require a larger sheath size, and the AngioVac requires transesophageal echocardiography under general anesthesia. Given the lack of comparison studies, use of either system depends on local availability, expertise, and patient risks.POCUS has the unique ability to provide a rapid multiorgan ultrasonography evaluation,8Nazerian P. Vanni S. Volpicelli G. et al.Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism.Chest. 2014; 145: 950-957Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar and its high diagnostic accuracy for PE is well illustrated by the demonstration of a thrombus-in-transit in this patient.5Biney I. Turner J.F. McKeown P. Soto F.J. Akhtar Y. Acute pulmonary embolism associated with a mobile right atrial thrombus managed by suction thrombectomy [abstract].Chest. 2019; 156: A911Abstract Full Text Full Text PDF Google Scholar,9Jabbour E. Malik D. Shiloh A.L. Sudden cardiopulmonary collapse in a patient with coronavirus disease 2019.Chest. 2021; 159: e127-e129Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar POCUS also can help to identify findings of right-heart strain that are associated with the presence of submassive PE.10Bikdeli B. Lobo J.L. Jimenez D. et al.Early use of echocardiography in patients with acute pulmonary embolism: findings from the RIETE Registry.J Am Heart Assoc. 2018; 7e009042Crossref PubMed Scopus (24) Google Scholar Such findings include the presence of right atrial dilatation, right ventricular dilatation, a D-shaped interventricular septum, and right ventricular dysfunction determined either by visual assessment or more objectively by demonstrating a reduced tricuspid annular plane systolic excursion with the help of M-mode. By identifying features of submassive PE,10Bikdeli B. Lobo J.L. Jimenez D. et al.Early use of echocardiography in patients with acute pulmonary embolism: findings from the RIETE Registry.J Am Heart Assoc. 2018; 7e009042Crossref PubMed Scopus (24) Google Scholar POCUS also could stratify the severity of the embolic event, playing a very important role in the rapid diagnostic evaluation of acute cardiopulmonary illnesses.11Koenig S. Mayo P. Volpicelli G. Millington S.J. Lung ultrasound scanning for respiratory failure in acutely ill patients: a review.Chest. 2020; 158: 2511-2516Abstract Full Text Full Text PDF PubMed Scopus (8) Google ScholarComprehensive assessment of this patient suggested that the acute neurologic changes were related to her underlying seizure disorder and not to an embolic event. The right-heart thrombus-in-transit was in incidental finding. The thrombus-in-transit diagnosis with POCUS was triggered by the initial identification of asymptomatic bilateral PE on head and neck CTA and by the patient’s subsequent admission to the ICU. This patient did not show radiologic or echocardiographic criteria for submassive PE. The decision to proceed with suction thrombectomy was based on the presence of a large thrombus-in-transit.Reverberations1.POCUS can provide a rapid multiorgan ultrasonography evaluation in patients with suspected or confirmed PE.2.POCUS rapidly can exclude (or confirm) echocardiographic characteristics suggestive of submassive PE.3.Identification of right-heart thrombus-in-transit is associated with an increased risk of death in PE, and its identification should prompt additional therapeutic considerations.4.ICE can be performed safely under conscious sedation. It provides high-resolution real-time visualization of cardiac structures and could have a promising role in guiding extraction of a right-heart thrombus-in-transit. A 66-year-old woman admitted for encephalitis and focal status epilepticus demonstrated a sudden right facial droop and lethargy 2 weeks into hospitalization. Head and neck CT scan angiography (CTA) showed unremarkable results except for incidental bilateral pulmonary emboli (PE), subsequently confirmed on chest CTA (Fig 1). Despite the clot burden documented on CTA and except for borderline tachycardia (heart rate, 103 beats/min), the remaining vital signs were in the normal range, including a normal oxygen saturation on room air. A cardiac point-of-care ultrasonography (POCUS) examination was performed (Video 1) at the time of admission to the ICU. Question: Based on the POCUS video and the additional patient data, which finding on the video should lead to urgent interventions? Answer: A large right heart thrombus-in-transit. Videos 1 and 2 show a mobile right heart thrombus. DiscussionPOCUS findings included a mobile right heart mass, a normal right atrial size, and a grossly normal right ventricular size and function (Video 1). POCUS findings were confirmed by a formal transthoracic echocardiogram that showed a mobile 4 × 2.6-cm right heart mass, normal estimated right-heart pressures, and preserved right ventricular function based on tricuspid annular plane systolic excursion assessment (Fig 2, Video 2). DVT also was identified in the left lower extremity. Progressive thrombocytopenia had been documented (32,000/μL), and argatroban was initiated. Platelet factor 4 immunoassay results were indeterminate. Given the patient’s history of left frontal focal seizures and the negative brain imaging results, the neurology service suspected focal seizure activity to be the reason for the acute neurologic changes. A bubble study was not pursued given the negative brain imaging results and the lack of evidence to suggest an acute stroke after formal neurologic evaluation. The patient’s acute deficits resolved within 24 h of ICU admission.Given the high mortality risk for thrombus-in-transit,1Barrios D. Rosa-Salazar V. Morillo R. et al.Prognostic significance of right heart thrombi in patients with acute symptomatic pulmonary embolism: systematic review and meta-analysis.Chest. 2017; 151: 409-416Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar thrombectomy and thrombolytics were considered in this patient. Penumbra Indigo CAT8 (Penumbra, Inc.) suction thrombectomy was pursued based on local availability. This required dual right femoral vein access for the 8.5-F Penumbra sheath and the intracardiac echocardiography (ICE) probe. ICE was favored over transesophageal echocardiography for its ability to visualize the right heart directly under conscious sedation. ICE largely has replaced transesophageal echocardiography for procedures such as atrial septal defect closure and catheter ablation of cardiac arrhythmias. Benefits include excellent patient tolerance, reduction of fluoroscopy time, and lack of need for general anesthesia.2Enriquez A. Saenz L.C. Rosso R. et al.Use of intracardiac echocardiography in interventional cardiology: working with the anatomy rather than fighting it.Circulation. 2018; 137: 2278-2294Crossref PubMed Scopus (112) Google Scholar In this patient, ICE provided optimal images of the thrombus-in-transit (Fig 3A). A snare was used to hold and break the clot while applying continuous suction, and the clot was aspirated successfully (Fig 3B, 3C, Video 3). Because the patient remained asymptomatic and was fully anticoagulated, no PE aspiration was performed, and CTA was not repeated.Figure 3A, Intracardiac echocardiogram with a short axis view at the level of the AV showing a large thrombus in the RA crossing the tricuspid valve into the RV (arrow). B, Penumbra suction embolectomy catheter in the right atrium (arrow). C, Successful suction thrombectomy with minimal residual clot. AV = aortic valve; RA = right atrium; RV = right ventricle; RVOT = right ventricle outflow tract.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Optimal treatment for right heart thrombi is not well defined.1Barrios D. Rosa-Salazar V. Morillo R. et al.Prognostic significance of right heart thrombi in patients with acute symptomatic pulmonary embolism: systematic review and meta-analysis.Chest. 2017; 151: 409-416Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar,3Galeano-Valle F. Demelo-Rodriguez P. Garcia-Fernandez-Bravo I. et al.Early surgical treatment in patients with pulmonary embolism and thrombus-in-transit.J Thorac Dis. 2018; 10: 2338-2345Crossref PubMed Scopus (2) Google Scholar Penumbra Indigo recently was studied4Sista A.K. Horowitz J.M. Tapson V.F. et al.Indigo aspiration system for treatment of pulmonary embolism.JACC Cardiovasc Interv. 2021; 14: 319-329Crossref PubMed Scopus (44) Google Scholar and approved for PE aspiration, but to our knowledge, this is its first reported use for aspiration of a thrombus-in-transit.5Biney I. Turner J.F. McKeown P. Soto F.J. Akhtar Y. Acute pulmonary embolism associated with a mobile right atrial thrombus managed by suction thrombectomy [abstract].Chest. 2019; 156: A911Abstract Full Text Full Text PDF Google Scholar In this patient, the small sheath size was ideal given the patient’s higher bleeding risk. However, for large in-transit clots, additional tools may be needed and clot fragments could migrate. The newer Penumbra Indigo CAT12’s larger 12-F lumen could be an additional alternative for such patients. The AngioVac (a 26-F sheath; AngioDynamics, Inc) and FlowTriever (a 22-F sheath; Inari Medical, Inc) also are approved6Rali P.M. Criner G.J. Submassive pulmonary embolism.Am J Respir Crit Care Med. 2018; 198: 588-598Crossref PubMed Scopus (33) Google Scholar,7Giri J. Sista A.K. Weinberg I. et al.Interventional therapies for acute pulmonary embolism: current status and principles for the development of novel evidence: a scientific statement from the American Heart Association.Circulation. 2019; 140: e774-e801Crossref PubMed Scopus (125) Google Scholar for suction thrombectomy in PE (and right-heart thrombectomy for AngioVac), but were not available to us at the time of the patient’s presentation. Notably, they require a larger sheath size, and the AngioVac requires transesophageal echocardiography under general anesthesia. Given the lack of comparison studies, use of either system depends on local availability, expertise, and patient risks.POCUS has the unique ability to provide a rapid multiorgan ultrasonography evaluation,8Nazerian P. Vanni S. Volpicelli G. et al.Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism.Chest. 2014; 145: 950-957Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar and its high diagnostic accuracy for PE is well illustrated by the demonstration of a thrombus-in-transit in this patient.5Biney I. Turner J.F. McKeown P. Soto F.J. Akhtar Y. Acute pulmonary embolism associated with a mobile right atrial thrombus managed by suction thrombectomy [abstract].Chest. 2019; 156: A911Abstract Full Text Full Text PDF Google Scholar,9Jabbour E. Malik D. Shiloh A.L. Sudden cardiopulmonary collapse in a patient with coronavirus disease 2019.Chest. 2021; 159: e127-e129Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar POCUS also can help to identify findings of right-heart strain that are associated with the presence of submassive PE.10Bikdeli B. Lobo J.L. Jimenez D. et al.Early use of echocardiography in patients with acute pulmonary embolism: findings from the RIETE Registry.J Am Heart Assoc. 2018; 7e009042Crossref PubMed Scopus (24) Google Scholar Such findings include the presence of right atrial dilatation, right ventricular dilatation, a D-shaped interventricular septum, and right ventricular dysfunction determined either by visual assessment or more objectively by demonstrating a reduced tricuspid annular plane systolic excursion with the help of M-mode. By identifying features of submassive PE,10Bikdeli B. Lobo J.L. Jimenez D. et al.Early use of echocardiography in patients with acute pulmonary embolism: findings from the RIETE Registry.J Am Heart Assoc. 2018; 7e009042Crossref PubMed Scopus (24) Google Scholar POCUS also could stratify the severity of the embolic event, playing a very important role in the rapid diagnostic evaluation of acute cardiopulmonary illnesses.11Koenig S. Mayo P. Volpicelli G. Millington S.J. Lung ultrasound scanning for respiratory failure in acutely ill patients: a review.Chest. 2020; 158: 2511-2516Abstract Full Text Full Text PDF PubMed Scopus (8) Google ScholarComprehensive assessment of this patient suggested that the acute neurologic changes were related to her underlying seizure disorder and not to an embolic event. The right-heart thrombus-in-transit was in incidental finding. The thrombus-in-transit diagnosis with POCUS was triggered by the initial identification of asymptomatic bilateral PE on head and neck CTA and by the patient’s subsequent admission to the ICU. This patient did not show radiologic or echocardiographic criteria for submassive PE. The decision to proceed with suction thrombectomy was based on the presence of a large thrombus-in-transit. POCUS findings included a mobile right heart mass, a normal right atrial size, and a grossly normal right ventricular size and function (Video 1). POCUS findings were confirmed by a formal transthoracic echocardiogram that showed a mobile 4 × 2.6-cm right heart mass, normal estimated right-heart pressures, and preserved right ventricular function based on tricuspid annular plane systolic excursion assessment (Fig 2, Video 2). DVT also was identified in the left lower extremity. Progressive thrombocytopenia had been documented (32,000/μL), and argatroban was initiated. Platelet factor 4 immunoassay results were indeterminate. Given the patient’s history of left frontal focal seizures and the negative brain imaging results, the neurology service suspected focal seizure activity to be the reason for the acute neurologic changes. A bubble study was not pursued given the negative brain imaging results and the lack of evidence to suggest an acute stroke after formal neurologic evaluation. The patient’s acute deficits resolved within 24 h of ICU admission. Given the high mortality risk for thrombus-in-transit,1Barrios D. Rosa-Salazar V. Morillo R. et al.Prognostic significance of right heart thrombi in patients with acute symptomatic pulmonary embolism: systematic review and meta-analysis.Chest. 2017; 151: 409-416Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar thrombectomy and thrombolytics were considered in this patient. Penumbra Indigo CAT8 (Penumbra, Inc.) suction thrombectomy was pursued based on local availability. This required dual right femoral vein access for the 8.5-F Penumbra sheath and the intracardiac echocardiography (ICE) probe. ICE was favored over transesophageal echocardiography for its ability to visualize the right heart directly under conscious sedation. ICE largely has replaced transesophageal echocardiography for procedures such as atrial septal defect closure and catheter ablation of cardiac arrhythmias. Benefits include excellent patient tolerance, reduction of fluoroscopy time, and lack of need for general anesthesia.2Enriquez A. Saenz L.C. Rosso R. et al.Use of intracardiac echocardiography in interventional cardiology: working with the anatomy rather than fighting it.Circulation. 2018; 137: 2278-2294Crossref PubMed Scopus (112) Google Scholar In this patient, ICE provided optimal images of the thrombus-in-transit (Fig 3A). A snare was used to hold and break the clot while applying continuous suction, and the clot was aspirated successfully (Fig 3B, 3C, Video 3). Because the patient remained asymptomatic and was fully anticoagulated, no PE aspiration was performed, and CTA was not repeated. Optimal treatment for right heart thrombi is not well defined.1Barrios D. Rosa-Salazar V. Morillo R. et al.Prognostic significance of right heart thrombi in patients with acute symptomatic pulmonary embolism: systematic review and meta-analysis.Chest. 2017; 151: 409-416Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar,3Galeano-Valle F. Demelo-Rodriguez P. Garcia-Fernandez-Bravo I. et al.Early surgical treatment in patients with pulmonary embolism and thrombus-in-transit.J Thorac Dis. 2018; 10: 2338-2345Crossref PubMed Scopus (2) Google Scholar Penumbra Indigo recently was studied4Sista A.K. Horowitz J.M. Tapson V.F. et al.Indigo aspiration system for treatment of pulmonary embolism.JACC Cardiovasc Interv. 2021; 14: 319-329Crossref PubMed Scopus (44) Google Scholar and approved for PE aspiration, but to our knowledge, this is its first reported use for aspiration of a thrombus-in-transit.5Biney I. Turner J.F. McKeown P. Soto F.J. Akhtar Y. Acute pulmonary embolism associated with a mobile right atrial thrombus managed by suction thrombectomy [abstract].Chest. 2019; 156: A911Abstract Full Text Full Text PDF Google Scholar In this patient, the small sheath size was ideal given the patient’s higher bleeding risk. However, for large in-transit clots, additional tools may be needed and clot fragments could migrate. The newer Penumbra Indigo CAT12’s larger 12-F lumen could be an additional alternative for such patients. The AngioVac (a 26-F sheath; AngioDynamics, Inc) and FlowTriever (a 22-F sheath; Inari Medical, Inc) also are approved6Rali P.M. Criner G.J. Submassive pulmonary embolism.Am J Respir Crit Care Med. 2018; 198: 588-598Crossref PubMed Scopus (33) Google Scholar,7Giri J. Sista A.K. Weinberg I. et al.Interventional therapies for acute pulmonary embolism: current status and principles for the development of novel evidence: a scientific statement from the American Heart Association.Circulation. 2019; 140: e774-e801Crossref PubMed Scopus (125) Google Scholar for suction thrombectomy in PE (and right-heart thrombectomy for AngioVac), but were not available to us at the time of the patient’s presentation. Notably, they require a larger sheath size, and the AngioVac requires transesophageal echocardiography under general anesthesia. Given the lack of comparison studies, use of either system depends on local availability, expertise, and patient risks. POCUS has the unique ability to provide a rapid multiorgan ultrasonography evaluation,8Nazerian P. Vanni S. Volpicelli G. et al.Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism.Chest. 2014; 145: 950-957Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar and its high diagnostic accuracy for PE is well illustrated by the demonstration of a thrombus-in-transit in this patient.5Biney I. Turner J.F. McKeown P. Soto F.J. Akhtar Y. Acute pulmonary embolism associated with a mobile right atrial thrombus managed by suction thrombectomy [abstract].Chest. 2019; 156: A911Abstract Full Text Full Text PDF Google Scholar,9Jabbour E. Malik D. Shiloh A.L. Sudden cardiopulmonary collapse in a patient with coronavirus disease 2019.Chest. 2021; 159: e127-e129Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar POCUS also can help to identify findings of right-heart strain that are associated with the presence of submassive PE.10Bikdeli B. Lobo J.L. Jimenez D. et al.Early use of echocardiography in patients with acute pulmonary embolism: findings from the RIETE Registry.J Am Heart Assoc. 2018; 7e009042Crossref PubMed Scopus (24) Google Scholar Such findings include the presence of right atrial dilatation, right ventricular dilatation, a D-shaped interventricular septum, and right ventricular dysfunction determined either by visual assessment or more objectively by demonstrating a reduced tricuspid annular plane systolic excursion with the help of M-mode. By identifying features of submassive PE,10Bikdeli B. Lobo J.L. Jimenez D. et al.Early use of echocardiography in patients with acute pulmonary embolism: findings from the RIETE Registry.J Am Heart Assoc. 2018; 7e009042Crossref PubMed Scopus (24) Google Scholar POCUS also could stratify the severity of the embolic event, playing a very important role in the rapid diagnostic evaluation of acute cardiopulmonary illnesses.11Koenig S. Mayo P. Volpicelli G. Millington S.J. Lung ultrasound scanning for respiratory failure in acutely ill patients: a review.Chest. 2020; 158: 2511-2516Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Comprehensive assessment of this patient suggested that the acute neurologic changes were related to her underlying seizure disorder and not to an embolic event. The right-heart thrombus-in-transit was in incidental finding. The thrombus-in-transit diagnosis with POCUS was triggered by the initial identification of asymptomatic bilateral PE on head and neck CTA and by the patient’s subsequent admission to the ICU. This patient did not show radiologic or echocardiographic criteria for submassive PE. The decision to proceed with suction thrombectomy was based on the presence of a large thrombus-in-transit. Reverberations1.POCUS can provide a rapid multiorgan ultrasonography evaluation in patients with suspected or confirmed PE.2.POCUS rapidly can exclude (or confirm) echocardiographic characteristics suggestive of submassive PE.3.Identification of right-heart thrombus-in-transit is associated with an increased risk of death in PE, and its identification should prompt additional therapeutic considerations.4.ICE can be performed safely under conscious sedation. It provides high-resolution real-time visualization of cardiac structures and could have a promising role in guiding extraction of a right-heart thrombus-in-transit. 1.POCUS can provide a rapid multiorgan ultrasonography evaluation in patients with suspected or confirmed PE.2.POCUS rapidly can exclude (or confirm) echocardiographic characteristics suggestive of submassive PE.3.Identification of right-heart thrombus-in-transit is associated with an increased risk of death in PE, and its identification should prompt additional therapeutic considerations.4.ICE can be performed safely under conscious sedation. It provides high-resolution real-time visualization of cardiac structures and could have a promising role in guiding extraction of a right-heart thrombus-in-transit. Financial/nonfinancial disclosures: None declared. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. Additional information: Videos for this case are available under “Supplementary Data.” Supplementary Datahttps://journal.chestnet.org/cms/asset/7e0f386c-bca5-46d5-9ef5-fd7e5828135d/mmc1.mp4Loading ... Download .mp4 (65.19 MB) Help with .mp4 files Video 1Point-of-care ultrasonography apical four-chamber cardiac view showing a large mobile right atrial thrombus crossing the tricuspid valve into the right ventricle and no significant right ventricular strain.https://journal.chestnet.org/cms/asset/95640de7-288e-46b8-b08e-87930471119f/mmc2.mp4Loading ... Download .mp4 (0.63 MB) Help with .mp4 files Video 2Apical four-chamber view of transthoracic echocardiography showing a large mobile right atrial thrombus crossing the tricuspid valve into the right ventricle and no significant right ventricular strain.https://journal.chestnet.org/cms/asset/76d87742-bc53-490f-98e3-5f4ca0416608/mmc3.mp4Loading ... Download .mp4 (0.41 MB) Help with .mp4 files Video 3Intracardiac echocardiography showing a large mobile right atrial thrombus crossing the tricuspid valve into the right ventricle. This is followed by suction thrombectomy being performed with the Penumbra suction embolectomy catheter in the right atrium by applying continuous suction. Final images reveal minimal residual intracardiac thrombus.https://journal.chestnet.org/cms/asset/fdd0e883-8f1b-43b8-a09d-dbc73f904b9d/mmc4.mp4Loading ... Download .mp4 (4.26 MB) Help with .mp4 files VIdeo 4 https://journal.chestnet.org/cms/asset/7e0f386c-bca5-46d5-9ef5-fd7e5828135d/mmc1.mp4Loading ... Download .mp4 (65.19 MB) Help with .mp4 files Video 1Point-of-care ultrasonography apical four-chamber cardiac view showing a large mobile right atrial thrombus crossing the tricuspid valve into the right ventricle and no significant right ventricular strain.https://journal.chestnet.org/cms/asset/95640de7-288e-46b8-b08e-87930471119f/mmc2.mp4Loading ... Download .mp4 (0.63 MB) Help with .mp4 files Video 2Apical four-chamber view of transthoracic echocardiography showing a large mobile right atrial thrombus crossing the tricuspid valve into the right ventricle and no significant right ventricular strain.https://journal.chestnet.org/cms/asset/76d87742-bc53-490f-98e3-5f4ca0416608/mmc3.mp4Loading ... Download .mp4 (0.41 MB) Help with .mp4 files Video 3Intracardiac echocardiography showing a large mobile right atrial thrombus crossing the tricuspid valve into the right ventricle. This is followed by suction thrombectomy being performed with the Penumbra suction embolectomy catheter in the right atrium by applying continuous suction. Final images reveal minimal residual intracardiac thrombus.https://journal.chestnet.org/cms/asset/fdd0e883-8f1b-43b8-a09d-dbc73f904b9d/mmc4.mp4Loading ... Download .mp4 (4.26 MB) Help with .mp4 files VIdeo 4