Free-floating thrombus in the right heart and pulmonary embolism

Bedside echocardiography for undifferentiated hypotension: diagnosis of a right heart thrombus

A free-floating right heart thrombus is often a harbinger of a massive pulmonary embolism and must be diagnosed and treated rapidly in order to avoid significant adverse sequelae. We present the case of an 84-year-old female who presented with two days of dyspnea and was hypotensive on arrival. Bedside ultrasound was performed by the emergency physician and showed a large, mobile right heart thrombus leading to immediate administration of a thrombolytic. In this case, bedside ultrasound was utilized to help further delineate clinical care in a progressively worsening patient, leading to a potentially lifesaving treatment.

Fatal evolution of a huge right atrial free-floating thrombus

Key Clinical Message

Right atrial thrombus is a rare medical emergency that should be suspected in all cases of pulmonary embolism, and rapid action should be taken to ensure a timely, proper management.

Emergency department focused bedside echocardiography in massive pulmonary embolism

BACKGROUND

Massive pulmonary embolism (PE) is a common consideration in unstable patients presenting to the emergency department (ED) with chest pain, dyspnea, or cardiac arrest. It is a potentially lethal condition necessitating prompt recognition and aggressive management. Conventional diagnostic modalities in the ED, including chest computed tomography angiography and ventilation-perfusion scanning, require the unstable patient to leave the department, and raise concerns over renal injury. Several case reports document findings of massive PE on echocardiography performed in the ED; however, none was performed, interpreted, and acted upon in the form of thrombolytic therapy by an emergency physician without the additional benefit of a cardiologist's interpretation or a confirmatory imaging study.

OBJECTIVE

We present a case that illustrates the utility of ED focused bedside echocardiography in suspected massive PE and briefly review direct and indirect ultrasound findings of acute PE.

CASE REPORT

A case of massive PE in a 61-year-old woman is reported. In this patient with marked dyspnea, progressive hemodynamic instability, and contraindications to definitive imaging, ED focused bedside echocardiography provided valuable information that strongly suggested the diagnosis and led to alteplase administration. To our knowledge, this case represents the first report of thrombolytic therapy administration for acute massive PE based solely on clinical presentation and an emergency physician-performed bedside echocardiogram.

CONCLUSION

In the hands of an experienced emergency physician ultrasonographer, ED focused bedside echocardiography provides a safe, rapid, and non-invasive diagnostic adjunct for evaluation of the patient suspected of having massive PE.

Right atrial free-floating thrombus in a patient with massive pulmonary embolism: A case of ‘emboli in transit’

A 78-year-old man was admitted with sudden onset of dyspnea followed by syncope. Contrast-enhanced computed tomography showed embolism in the right main pulmonary artery and left upper pulmonary artery. Echocardiography revealed a large, free-floating thrombus and cine magnetic resonance imaging showed highly mobile, low-signal intensity mass in the right atrium, which protruded into the right ventricle during diastole. During surgery the thrombus migrated into the pulmonary artery trunk, but it was successfully removed.