Right heart thrombus in a patient with acute pulmonary embolism-a practice in hide-and-seek with guidelines

Introduction. Right heart thrombus (RHT) is a relatively rare phenomenon found in 4% of patients with acute pulmonary embolism (PE), and some reports show that the presence of RHT is associated with poor outcomes. The optimal treatment of patients with PE and RHT is still controversial, with no clear consensus. Case report. A 38-year-old woman with repeated chest pain and wors-ening dyspnea was admitted to the hospital. The echocar-diographical exam showed a large thrombus floating in the right atrium, protruding through the tricuspid valve into the right ventricle. Massive bilateral pulmonary embolism was confirmed by computed tomography pulmonary angi-ogram. Bearing these findings in mind and due to the clin-ical and hemodynamic instability of the patient, thrombo-lytic therapy was immediately initiated (alteplase), which resulted in excellent clinical outcomes with no adverse events at follow-up. Conclusion. Treating patients with PE and RHT is very difficult. While waiting for the results of some future randomized clinical trials on this topic, the treatment of these patients should be based on current guidelines while also considering the patient's hemody-namic stability.