Massive pulmonary embolus and a precariously positioned thrombus: teetering on a knife edge!

Pulmonary embolism (PE) is a common condition seen regularly by emergency physicians. The authors describe a patient who presented with shortness of breath and syncope. He also experienced drowsy, clammy and sweaty episodes. He was tachycardic, tachypnoeic and saturating at 92% on air. A chest X-ray was normal but an ECG showed S1Q3T3. A CT pulmonary angiography performed showed bilateral pulmonary emboli with a large inferior vena cava (IVC) thrombus. Echocardiography revealed severely dilated right ventricle and atrium, severe right ventricular impairment, pulmonary hypertension, large mobile friable clots seen extending into the tricuspid valve. A multidisciplinary team decided the safest management approach was intravenous heparin. The patient recovered and repeat echocardiography 5 days later showed significantly smaller clots. The extension of an IVC thrombus into the heart and prolapsing into the tricuspid valve is an extremely rare presentation. Furthermore this case demonstrates the importance of echocardiography when diagnosing and generating bespoke management plans for PE.