Massive right atrial thrombus.

Case description

A 70-year-old Caucasian man with a past medical history of hypertension, significant smoking history, and atrial fibrillation presented to the emergency department with complaints of chest pain and dizziness. The chest pain began 5 h prior to presentation; it was described as dull, retrosternal, non-radiating, and associated with a sensation of dizziness. Of note, the patient had initially been prescribed apixaban, however, during an outpatient visit with his primary care physician, a decrease in haemoglobin was noted and due to concerns for gastrointestinal bleed, apixaban was held 4 months prior to presentation. An electrocardiogram showed atrial fibrillation with a rapid ventricular response. Vitals upon arrival showed a blood pressure of 136/84, heart rate of 128 p.m., respiratory rate of 16 breath/min, and oxygen saturation of 97% with nasal cannula flow of 5 L/min. Physical exam was remarkable for an irregular heart rate and rhythm, and decreased breath sounds at the right lower lung base. Troponin levels were normal. Chest X-ray demonstrated mild cardiomegaly and a right pleural effusion. Left venous lower extremity duplex was positive for deep vein thrombosis of the popliteal and gastrocnemius veins. A transthoracic echocardiogram (TTE) was performed which showed a normal sized right ventricle with normal function. Most notable was the presence of a large mobile echogenic mass swirling around in the right atrium, consistent with a thrombus in transit, elevated pulmonary artery systolic pressures, and severely reduced left ventricular function (). Computed tomography pulmonary angiography demonstrated vermiform filling defects in the right atrium extending to the inferior vena cava and right ventricle, dilation of the right ventricle and right atrium with increased right cardiac pressures, segmental acute pulmonary embolism in the left lower lobe, and chronic pulmonary embolism in the right main pulmonary artery extending to the proximal right middle lobe pulmonary artery (). Rate control management for atrial fibrillation and weight-based protocol for venous thromboembolism with intravenous unfractioned heparin infusion was initiated. Subsequently, the patient was admitted to the cardiac care unit, with repeat TTE after 8 h, showing resolution of thrombus.

Figure 1

Transthoracic echocardiogram showing a large mobile thrombus in the right atrium (RA) and crossing into right ventricle (RV).

Figure 2

Coronal view of thoracic computed tomography showing a large vermiform filling defect in the right ventricle and atrium.

Supplementary material

Supplementary material is available at European Heart Journal - Case Reports online.

Consent: The authors confirm that written consent for submission and publication of this case report including image(s) and associated text has been obtained from the patient in line with COPE guidance.

Conflict of interest: none declared.

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