Key result
Sequential IV UFH followed by apixaban resolves a serpentine right atrial thrombus in 15 days.
Why the study?
Serpentine right atrial thrombus is a rare, life-threatening condition with an extremely poor prognosis if untreated, and literature supporting oral anticoagulation in high-bleeding-risk, hemodynamically stable patients is sparse.
Does intravenous unfractionated heparin followed by oral apixaban resolve serpentine right atrial thrombus in a hemodynamically stable patient with pulmonary embolism and high bleeding risk?
Case Report (n=1)
No
Does intravenous unfractionated heparin followed by oral apixaban resolve serpentine right atrial thrombus in a hemodynamically stable patient with pulmonary embolism and high bleeding risk?
Oral anticoagulation with apixaban following a brief heparin bridge may be a viable therapeutic option for serpentine right atrial thrombus in hemodynamically stable patients with high bleeding risk when interventional strategies are unavailable.
Requires urgent intervention to prevent embolization despite stability; leaves open optimal strategy for serpentine thrombi in elderly.
Serpentine thrombus, also referred to as a snake-like or worm-like floating thrombus, is a rare but life-threatening intracardiac condition representing a true therapeutic emergency. Without treatment, the prognosis is extremely poor. The condition is particularly dangerous due to the risk of thrombus fragmentation and migration, which can lead to complete obstruction of the pulmonary trunk. We report the case of an 80-year-old hemodynamically stable man who presented with progressive dyspnea and severe hypoxemia. Computed tomography pulmonary angiography confirmed bilateral proximal pulmonary embolism, and transthoracic echocardiography (TTE) identified a serpiginous free-floating thrombus in the right atrium, prolapsing into the right ventricle during diastole. Significant right ventricular dysfunction and severe pulmonary hypertension (estimated pulmonary artery pressure 67 mmHg) were documented. Risk stratification yielded a Pulmonary Embolism Severity Index (PESI) score of 110 (Class IV, high risk) and a Venous Thromboembolism Bleeding (VTE-BLEED) score of 3 (high bleeding risk). Given hemodynamic stability and elevated bleeding risk, systemic thrombolysis was deferred. The patient was initially managed with intravenous unfractionated heparin for five days, followed by oral anticoagulation with apixaban (10 mg twice daily for seven days, then 5 mg twice daily). Complete resolution of the intracardiac thrombus was confirmed on TTE on day 15, with concurrent clinical and respiratory improvement. This case adds to the sparse literature supporting oral anticoagulation as a viable therapeutic option in carefully selected, hemodynamically stable patients with serpentine right atrial thrombus and high bleeding risk, when more aggressive strategies are contraindicated or unavailable. It underscores the importance of individualized decision-making and long-term surveillance.
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Zrigui et al. (2026) conducted a case report in Bilateral pulmonary artery embolism and serpentine right atrial thrombus (n=1). Unfractionated heparin followed by apixaban was evaluated on Thrombus resolution. Sequential treatment with intravenous unfractionated heparin followed by oral apixaban achieved complete resolution of a serpentine right atrial thrombus by day 15 in an 80-year-old man.
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