Clinical significance and management of right heart thrombi: more questions than answers

Pulmonary embolism (PE) remains one of the leading causes of cardiovascular morbidity and mortality [1]. Acute PE has a spectrum of clinical syndromes and varying clinical outcomes [2, 3]. Estimation of patient prognosis helps to prioritise appropriate management strategies. Risk stratification of patients with PE may identify patients at high risk of early PE-related death who may benefit from escalated surveillance or therapy [4, 5]. Alternatively, clinicians may consider patients deemed at low risk for early complications ( i.e. all-cause mortality, recurrent venous thromboembolism (VTE), and major bleeding) as candidates for partial or complete outpatient PE treatment [6]. According to the recent European Society of Cardiology (ESC) guidelines [7], risk assessment of patients diagnosed with PE should rely on the sequential application of a validated clinical score ( i.e. pulmonary embolism severity index (PESI) or simplified PESI (sPESI)), imaging testing assessing right ventricle (RV) function ( i.e. echocardiography or computed tomographic pulmonary angiography), and cardiac biomarkers ( i.e. cardiac troponins). Though the guidelines state that patients who have acute PE associated with right heart thrombi (RHT) have a potentially life-threatening condition, the authors did not formally incorporate the presence or absence of RHT into their PE prognostication algorithm. Haemodynamic status has the strongest prognostic implications for short-term mortality in patients with PE