TYPE: Abstract Publication TOPIC: Pulmonary Vascular Disease PURPOSE: Discuss management of bilateral pulmonary emboli (PE) with the presence of a right ventricular (RV) thrombus. METHODS: A 37 year old female with morbid obesity presented for evaluation of acute onset chest pain and shortness of breath. She lacked traditional risk factors for thromboembolic disease. She was hemodynamically stable with the exception of tachycardia and tachypnea. RESULTS: EKG demonstrated sinus tachycardia. Labs showed troponin-I of 0.19 ng/mL and D-dimer of 1.22 mcg/mL FEU. CTA chest revealed PE in the bilateral main pulmonary arteries and lobar branches with thrombus in the RV. Contrast-enhanced echocardiogram confirmed RV thrombus, evidence of right heart strain, moderately reduced RV function and estimated at least moderate to severe pulmonary hypertension. CONCLUSIONS: Patient was started on intravenous heparin and underwent right heart catheterization confirming CTA findings showing pulmonary artery systolic pressure (PASP) of 79 mmHg, followed by pulmonary angiography with bilateral mechanical thrombectomy albeit with an unsuccessful attempt of RV thrombectomy. Catheter directed alteplase was initiated with two transfusion catheters. Repeat right heart catheterization revealed PASP of 64 mmHg, only moderate residual clot in the right pulmonary artery with good lung perfusion and minimal residual clot in the left pulmonary artery. She was bridged to warfarin and discharged home with marked symptom resolution. She has not yet had followup. CLINICAL IMPLICATIONS: Idiopathic RV thrombus is an uncommon finding that portends higher risk. Our patient’s acute symptoms resolved with an approach involving thrombectomy followed by catheter-directed lysis. Optimal treatment strategies for these intermediate to high risk PE with RV thrombus are still uncertain. DISCLOSURE: No significant relationships. KEYWORDS: Pulmonary Embolism, Right ventricular thrombus, Mechanical thrombectomy