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This echocardiogram was recorded from a 62 year old woman who presented with breathlessness and pleuritic chest pain. Three weeks before admission she had sprained her ankle and been forced to rest. Subsequently she noticed calf swelling, followed by a presyncopal episode just before the onset of her presenting symptoms. On admission, examination of her leg and Doppler studies of leg veins were normal. However, she had signs of right heart failure and an electrocardiographic pattern of right heart strain. Chest radiography was normal. On the basis of the echocardiogram a diagnosis of thrombus in the right atrium (RA) extending into the right ventricle (RV) was made (LA, left atrium; LV, left ventricle). She was treated with peripheral intravenous tissue plasminogen activator (tPA) (total dose 100 mg over 90 minutes). Repeat echocardiograms showed substantial resolution of the thrombus one hour after tPA and none was evident at 24 hours. The patient’s symptoms resolved and a ventilation perfusion lung scan did not show any evidence of pulmonary emboli. We propose that this patient developed a calf vein thrombosis secondary to immobility, which then embolised in total at the time of her presyncopal episode to lodge in the right atrium. Mechanisms by which the thrombus could have been caught as it passed through the right heart include entrapment by the tricuspid valve apparatus or the Chiari network (congenital remnants of the right venous valve of the sinus venosus). In this patient Chiari nets, which can be seen by echocardiography, were not detected.
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