Imaging and Risk Guided Management in Complex Cardiovascular Emergencies: A Focused Narrative Review of Right Heart Thrombosis in Pulmonary Embolism and Myocarditis Related Ventricular Arrhythmia

Complex cardiovascular emergencies often become dangerous not because a single diagnostic test is unavailable, but because rapidly changing physiology, an incompletely characterized substrate, and uncertain treatment effects must be interpreted together. This focused narrative review examines two uncommon but clinically important settings: right heart thrombosis accompanying acute pulmonary embolism and ventricular arrhythmia associated with myocarditis or inflammatory cardiomyopathy. In pulmonary embolism, echocardiography and computed tomography define right ventricular stress, identify intracardiac thrombus, and support early risk classification, while haemodynamic status remains central to treatment selection. In myocarditis, electrocardiography, ambulatory monitoring, echocardiography, cardiac magnetic resonance, and selected endomyocardial biopsy can reveal an inflammatory or scar-related substrate that may precede overt ventricular dysfunction. Published case-based evidence illustrates why a single reassuring study cannot replace serial reassessment and why apparently similar presentations may require different therapeutic pathways. Across both conditions, the most defensible strategy is a risk-guided sequence: stabilize the patient, identify the immediate mechanism, characterize the underlying substrate, reassess after intervention, and escalate through a multidisciplinary team when instability, recurrent events, or progressive ventricular dysfunction persists. Current evidence remains limited by observational designs and heterogeneous treatment selection. Prospective registries with standardized imaging, treatment definitions, and longitudinal outcomes are needed.