SESSION TITLE: Pulmonary Vascular Disease SESSION TYPE: Fellow Case Reports PRESENTED ON: 10/22/2019 3:45 PM - 4:45 PM INTRODUCTION: Pulmonary embolism (PE) associated with a free-floating right heart thrombus (RHT) carries a much higher mortality risk. Optimal management of RHT is controversial. Suction thrombectomy can be a viable treatment option. CASE PRESENTATION: A 66-year-old female was admitted for Rasmussen’s encephalitis. After 2 weeks in the hospital she developed sudden decreased motor skills, facial droop and lethargy. Computed tomography (CT) of the head and neck was unremarkable except for incidental large pulmonary emboli. CT angiogram of the chest confirmed PE extending from the distal main arteries into the lobar branches bilaterally (Fig. 1). An echocardiogram showed a 4x2.6 cm mobile mass within the right atrium that crossed the tricuspid valve (Fig. 2). She had been on deep vein thrombosis (DVT) prophylaxis throughout her hospital stay with subcutaneous heparin and over the 24-hour period preceding these events, her platelet count had decreased from 345,000 to 83,000. Argatroban infusion was started for suspected heparin induced thrombocytopenia. Venous doppler ultrasound showed a DVT in the left leg. She was hemodynamically stable with oxygen saturation in the upper 90’s on room air. However, the patient was considered to have a high mortality risk given her clot burden and the size of the mobile RHT. She was not a candidate for surgery or thrombolytics but considered a candidate for suction thrombectomy. During the procedure, intracardiac echocardiography identified a large thrombus completely filling the right atrium (Fig 3). The Penumbra® suction system was introduced via a 8.5 French sheath to perform the aspiration. Given the size of the thrombus, a snare was used to break up the clot while applying continuous suction with the penumbra device. Aspiration of the clot was successful with minimal residual clot present on the eustachian valve (Fig 4). Video images of the procedure were recorded. The patient did well after the procedure and was discharged on oral anticoagulation. DISCUSSION: There are several suction thrombectomy systems available. The smaller cannulas of the Penumbra® system provide the advantage of flexibility. To our knowledge, this is the first reported case using this system for the management of a RHT. The use of this device in intermediate-risk PE is currently being evaluated in a clinical trial. CONCLUSIONS: Given the lack of clear guidelines for management of RHT, suction thrombectomy with the Penumbra® system can be considered especially when thrombolytics are contraindicated. Further studies are however needed to assess its use for this indication. Reference #1: Barrios D, Rosa-Salazar V, Morillo R, Nieto R, Fernandez S, Zamorano JL, et al. Prognostic Significance of Right Heart Thrombi in Patients With Acute Symptomatic Pulmonary Embolism: Systematic Review and Meta-analysis. Chest. 2017;151(2):409-16. Reference #2: Nosher JL, Patel A, Jagpal S, Gribbin C, Gendel V. Endovascular treatment of pulmonary embolism: Selective review of available techniques. World journal of radiology. 2017;9(12):426-37. Reference #3: Evaluating the Safety and Efficacy of the Indigo Aspiration System in Acute Pulmonary Embolism (EXTRACT-PE) [Available from: https://clinicaltrials.gov/ct2/show/NCT03218566 DISCLOSURES: No relevant relationships by Yasir Akhtar, source=Web Response No relevant relationships by Isaac Biney, source=Web Response No relevant relationships by Peter McKeown, source=Admin input No relevant relationships by Francisco Soto, source=Web Response No relevant relationships by J Turner, source=Web Response