[Pulmonary embolism with right intra-auricular thrombus. Fatal outcome during fibrinolysis]

The spontaneous prognosis of pulmonary embolism associated with mobile intra-cardiac thrombus is most severe, and the choice of a therapeutic strategy is often difficult.

The treatment of a patient with intravenous fibrinolytics for massive pulmonary embolism and right atrium thrombus was complicated by his early death. We attributed his death to the migration of the intra-cardiac thrombus. Indeed, the cardiac ultrasound, performed when the patient's hemodynamic state had worsened, revealed the complete disappearance of the thrombus too early to correspond to its complete lysis (30th minute of fibrinolysis).

In this pathology, several therapeutic approaches are possible. Surgical removal of the embolus has been validated, but cannot be proposed to all patients since it is a high-risk intervention. Fibrinolysis is generally efficient but exposes the patient to the risk of migration of the intra-cavity thrombus with occasionally deleterious evolution (as in our patient). Heparin treatment alone has been proposed as an alternative when the other two techniques are contraindicated. These techniques currently require assessment in a randomized study, in order to define the appropriate therapeutic strategy.