B64-46 Caught Mid-Flight - Surgical Embolectomy for Right Ventricular Thrombus in Transit

Abstract We describe a case in which an incidental finding of a large, golf-ball-sized thrombus in the right heart on a transthoracic echocardiogram prompted further evaluation with transesophageal echocardiography, which discovered a mobile thrombus in transit extending into the right main pulmonary artery. This unexpected finding led to immediate activation of the Pulmonary Embolism Response Team, and imaging confirmed that the mobile mass in the right heart was indeed a massive pulmonary embolism, causing significant strain to the right heart. This resulted in emergent involvement of cardiothoracic surgery.The patient is a 78-year-old woman with a history of hypertension who presented with worsening shortness of breath and fatigue. Upon initial evaluation, she was found to be mildly hypoxemic with severe AKI. Her clinical picture initially was interpreted as fluid overload due to undiagnosed heart failure, as the suspicion for a pulmonary embolism was low. A CT angiogram had been considered but ultimately deferred due to concern of contrast-induced nephropathy and worsening of AKI. A ventilation-perfusion scan was performed, but it was inconclusive. A duplex ultrasound of the lower extremities demonstrated acute deep venous thrombosis (DVT) in the right gastrocnemius with no DVT in the left extremity, and cardiac imaging was performed to evaluate for potential embolic burden.The transthoracic echocardiogram demonstrated a markedly dilated right ventricle with a large, mobile intracardiac mass. Transesophageal echocardiography confirmed the early findings of a thrombus extending from the right atrium into the pulmonary artery, which is consistent with “thrombus in transit.” Because of the considerable risk of sudden cardiovascular collapse and renal impairment, which precluded thrombolytic therapy consideration, the multidisciplinary team made the decision to proceed with an emergent open thrombectomy of the pulmonary artery and right atrium. Surgical findings confirmed the extensive burden of thrombus in both the right-sided chambers and out to the main pulmonary artery, which was effectively removed. Postoperatively, the patient required short-term mechanical ventilation and right ventricular support but improved in terms of oxygenation and hemodynamics. Patient was ultimately discharged to a rehabilitation center on long-acting oral anticoagulation with close outpatient follow-up. This abstract is funded by: None