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Right heart thromboemboli during pulmonary embolism (PE) implies a poor immediate prognosis. Management is still not well established, with treatment options including surgical embolectomy, anticoagulation, and thrombolysis. Transoesophageal echocardiography (TOE) has evolved as an important tool in the diagnosis and monitoring of patients with acute PE.
We describe the case of a 49 year old white woman with a history of colon cancer, under outpatient chemotherapy, who presented to the emergency department with recurrent episodes of rest dyspnoea, chest discomfort, and cough. High resolution spiral computed tomography (CT) showed multiple peripheral pulmonary emboli. Combined echocardiography (transthoracic and TOE) demonstrated a large 21 × 14 mm thrombus (panels A and B) attached to the lateral wall of the right atrium, and normal left ventricular (LV) and right ventricular (RV) function. She also had a Hickman catheter not related to the thrombotic mass. Doppler echocardiography revealed pulmonary hypertension with pulmonary artery (PA) systolic pressure estimated to be 49 mm Hg. A head CT was negative for bleeding or intracranial masses. Prolonged (96 hour) streptokinase infusion was started by peripheral venous access. Two days later a second TOE showed significant decrease of the thrombus (13 × 11 mm) (panel C) and a PA systolic pressure of 36 mm Hg. On her fifth hospital day at the end of thrombolytic infusion a third TOE examination demonstrated complete resolution of the thrombus (panel D) and near normalisation of PA systolic pressure (28 mm Hg). The patient had no haemorrhagic complications. She was placed on warfarin and was discharged home eight days after hospital admission.