Free-floating right heart thrombus is a rare phenomenon and 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.
An 84 year old Malay lady with underlying hypertension presented with acute history of generalised body weakness for 2 days and fever for 1 day. She was treated as septic shock secondary to urosepsis and supported on single vasopressor. Infective marker was significantly elevated. On day 2 in the emergency department, blood pressure was labile with type 1 respiratory failure. Bedside echocardiogram showed dilated right atrium and right ventricle. There was a small, mobile hyperechoic mass in the right atrium, intermittently protruding to the right ventricle. The inferior vena cava was plethoric. Two- point compression test was negative. Anticoagulation was prescribed and CT pulmonary artery done later reported as extensive pulmonary artery embolism involving pulmonary trunk and both pulmonary arteries. However, there was no obvious mass within the right atrium detected on CT. Despite treatment, she unfortunately succumbed to her illness and cause of death was attributed to extensive pulmonary embolism.
Right heart thrombi may develop within the right heart chambers (type B) or they may be a peripheral venous clots that lodge in the right heart (type A), known as right heart thrombi-in-transit.
Patients typically present acutely with low systolic blood pressure, right ventricular hypokinesis and congestive cardiac failure. Recommendations for treatment include anticoagulation therapy with heparin, administration of thrombolytic agents, or surgical removal of the thrombus. Management approaches differ with reports of lower mortality rates in patients who undergo surgical embolectomy as opposed to thrombolysis.
Free-floating right heart thrombus warrants early recognition and immediate therapeutic intervention with delay in treatment leading to a fatal outcome.
Pulmonary embolism-Right heart thrombus-Anticoagulation