Abstract
Free floating right heart thrombus is a rare phenomenon in the context of acute pulmonary embolism and it is associated with a poor outcome. The increased use of echocardiography has led to an increased detection of right heart thrombi. However, optimal management of free floating right heart thrombus remains controversial with no clear consensus. We present the case of a 74-year-old woman who presented to the emergency department with acute onset dyspnea on minimal exertion which had developed over a period of 1 day. A computed tomography of the chest demonstrated massive bilateral proximal pulmonary embolism. A bedside transthoracic echocardiography performed showed a moderately dilated, poorly functioning right ventricle with visible highly mobile serpiginous thrombus moving to and fro across the tricuspid valve. Thrombolytic therapy was immediately initiated with tenecteplase which resulted in excellent results. Although there is no clear consensus for the management of right heart thrombus associated with pulmonary embolism, thrombolysis is readily available and can be effective in carefully selected patients.
Highlights
Free floating right heart thrombus is a rare phenomenon in the context of acute pulmonary embolism and it is associated with a poor outcome
There is no clear consensus for the management of right heart thrombus associated with pulmonary embolism, thrombolysis is readily available and can be effective in carefully selected patients
Free floating right heart thrombus-in-transit is a rare phenomenon in the context of acute pulmonary embolism and is most commonly encountered in hemodynamically unstable patients with shorter duration of symptoms [1]
Summary
Free floating right heart thrombus-in-transit is a rare phenomenon in the context of acute pulmonary embolism and is most commonly encountered in hemodynamically unstable patients with shorter duration of symptoms [1]. The increased use of echocardiography has led to an increase in the detection of free floating right heart thrombi. Right heart thrombus is considered to be an extreme therapeutic emergency as it is associated with worse outcomes since they are an indication of imminent and potentially fatal pulmonary embolism [3,4,5]. The overall mortality rate in patients with right heart thrombus has been reported as 28% and as high as 100% in untreated patients [5]. The optimal therapy for right heart thrombus-in-transit still remains a therapeutic dilemma because prospective randomized controlled studies are scarce. Some report points to a better outcome with thrombolysis [2, 6]
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