SESSION TITLE: Cardiovascular Disease 2 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Right-heart thrombi (RHT) are identified in 7-18% of patients with massive pulmonary emboli. The treatment of RHT remains the subject of debate. We present the first reported case of RHT in transit treated with a direct oral anticoagulant CASE PRESENTATION: A 63-year-old woman with a history of major depressive disorder presented with six days of dyspnea and lower extremity edema. Vital signs on presentation were notable for a blood pressure of 70/68 mmHg, heart rate of 143 beats per minute, respiratory rate of 22, and oxygen saturation of 89% on room air. Examination revealed an obese woman in mild respiratory distress. The heart was tachycardic with a gallop, the lungs were clear to auscultation, and the lower extremities were warm with 2+ edema. Bilateral lower extremity pitting edema was present. Affect was guarded.Creatinine was 2.25 mg/dL (creatinine clearance 45 ml/min). Troponin T was 0.016 ng/mL. Electrocardiogram showed sinus tachycardia.Transthoracic echocardiography revealed evidence of right ventricular pressure overload, and a large, mobile echo density within the right atrium (Fig. 1). The right ventricular systolic pressure was estimated at 52 mmHg. The patient declined all further testing, including phlebotomy. She consented to oral medications. The patient was managed with the psychiatry service. She was deemed to have capacity to decline invasive procedures. With the significant barriers to therapy, a direct-acting oral anticoagulant was felt to be best therapeutic option. ,Apixaban and oral antidepressant medications were started. On hospital day 15, she was transferred to the inpatient psychiatry unit. Apixaban was continued. On hospital day 28, repeat echocardiogram revealed improvement in right ventricular size and function, and decrease in right ventricular systolic pressure to 32 mmHg. The right atrial thrombus was no longer visualized (Fig. 2). DISCUSSION: RHT-in-transit are associated with very high mortality, up to 40% even with treatment. Without treatment, they are almost uniformly fatal. A case series of 38 patients with RHT showed no statistical difference between various therapeutic options; thrombolysis, surgery and anticoagulation. Apixaban has been shown to be non-inferior to enoxaparin and warfarin for the treatment of VTE; however it has not been studied in patients with either massive PE or RHTIn this case, clinical circumstances dictated the use of a direct oral anticoagulant when other therapeutic options would otherwise have been used. The outcome in this case cannot be generalized to other patients presenting with either massive PE or RHT in the absence of further investigation CONCLUSIONS: RHT-in-transit are seen in a fraction of patients with massive PE and are associated with a high mortality despite intervention. This case illustrates satisfactory treatment of RHT-in-transit with apixaban due to limited therapeutic options Reference #1: Treatment of Right Heart Thrombi Associated. Deisy Barrios, MD,a Jeremy Chavant, MD,b David Jiménez, PhD,a Laurent Bertoletti, PhD,c Vladimir Rosa-Salazar, PhD. 5, s.l. : The American Journal of Medicine, 2017, Vol. 130 Reference #2: Oral Apixaban for the Treatment of Acute Venous Thromboembolism. Giancarlo Agnelli, Harry R. Bulle, Alexander Cohen, Madelyn Curto, Alexander S. Gallus, Margot Johnson, Urszula Masiukiewicz, Raphael Pak, John Thompson, Gary E. Raskob, and Jeffrey I. Weitz. 9, s.l. : The New England Journal of Medicine, 2013, Vol. 369. Reference #3: Outcome of patients with right heart thrombi: the Right Heart Thrombi European Registry. Marcin Koć, Maciej Kostrubiec, Waldemar Elikowski, Nicolas Meneveau, Mareike Lankeit, Stefano Grifoni, Agnieszka Kuch-Wocial, Antoniu Petris Beata Zaborska, Branislav S. Stefanović, Thomas Hugues, Adam Torbicki, Stavros Konstantinides and Piotr Pruszczyk. s.l. : European Respiratory Journal, 201 DISCLOSURES: no disclosure on file for David Ain; No relevant relationships by Omar Ayah, source=Web Response No relevant relationships by Jessica Joseph, source=Web Response No relevant relationships by Zainab Mahmoud, source=Web Response