Right heart thrombi (RHT) are rare but well-described entity in literature. Their isolation has been considered as confirmatory for the diagnosis of venous thromboembolism (VTE). Even though their isolation aids the diagnosis, physicians are faced with a difficult management dilemma giving the paucity of data to support any treatment decision. We present a case of RHT in an 81-year-old man who presented to hospital with a large mobile right heart thrombus in transit seen on transthoracic echocardiogram (TTE). He was successfully treated with anticoagulation alone. This case highlights the importance of TTE in establishing the diagnosis and describes the interplay of factors influencing treatment decision.
Right heart thrombi (RHT) are rare manifestation of venous thromboembolism (VTE); their presence is considered a marker for higher clot burden and worse outcome [
We present a case of right heart thrombi discovered on TTE emphasizing the utility of TTE in the setting of VTE. We aim also to describe the interplay of multiple clinical factors that may aid in treatment decision-making.
An 81-year-old man presented with syncope 3 days after inguinal hernia repair. His past medical history was significant for a deep venous thrombosis that was diagnosed 2 months earlier. Electrocardiogram on presentation demonstrated sinus tachycardia with a S1Q3T3 pattern (Figure
Electrocardiogram at presentation showing sinus tachycardia and S1Q3T3 pattern indicating right ventricular strain.
(a) An apical 4-chamber echocardiographic view of the heart showing the right heart thrombus protruding through the tricuspid valve. (b) A right ventricular inflow echocardiographic view of the heart showing the right heart thrombus protruding through the tricuspid valve.
Right heart thrombi (RHT) can be one of many potential causes of a right heart mass including congenital structures (e.g., Chiari network, persistent Eustachian valve, and atrial septal aneurysm) and acquired causes (e.g., leads, vegetation, or tumors) [
This case highlights the value of echocardiography with suspected pulmonary embolism. Although typical echocardiographic findings provide indirect evidence of pulmonary embolism, in the absence of prior cardiopulmonary disease these findings can be specific [
Treatment of RHT represents a management dilemma, given the absence of clear consensus treatment guidelines. Indeed, the need for appropriate therapy is most evident by the high mortality observed in the first 24 hours and an overall mortality in untreated patients approaching 100% [
Management strategies of varying risk have been proposed including pharmacological therapy with either intensive anticoagulation or thrombolysis and invasive therapy with either a catheter-based or surgical embolectomy. Comparative effectiveness studies evaluating these strategies have been limited by their small sample size and lack of randomization, both of which do not allow for a true understanding of the risks and benefits of each approach. For example, Finlayson described 38 cases of right heart thrombi where a similar and high (20–62%) in-hospital mortality was present regardless of the treatment modality used [
Thrombolytic therapy has been advocated as the first treatment modality [
Catheter aspiration thrombectomy has also been used with success in few reported cases [
Anticoagulation is not advocated as a sole therapy [
Given the limitations of each available therapy and lack of consensus on the management of patients with RHT, a personalized approach accounting for patient and institutional factors must be adopted for each patient.
Right heart thrombi
Venous thromboembolism.
The authors declare that there is no conflict of interests regarding the publication of this paper.