Acute Right Heart Failure in a Patient with Right Heart Thrombus and Pulmonary Thromboembolism

Right Heart Thrombus (RiHT) management is really controversial, and appropriate guidelines are not present for the management. In patients referring with RiHT and Pulmonary Embolism (PE), there are three ways of managing these patients. Out of the three, one is thrombectomy, which is with high risk taking in mind the comorbidities these patients have. The other is using thrombolytic which, in many cases is contraindicated or with high risk. The other less effective way is full anticoagulation. It is really controversial to choose between these ways of management and no clear approach is present. The case presented is a 44-year-old morbid obese male with history of dyspnea on exertion (functional Class II) and foot oedema or the last three months, who was transferred to the emergency department with respiratory distress and hypoxia. Echocardiography was done for the patient which showed moderate Right Ventricular (RV) dysfunction with severe RV enlargement and a severe Tricuspid Regurgitation (TR) with TR gradient of 70mmHg. He also had a semi-mobile large pedunculated mass in favour of a clot in his RV cavity. With the impression of PE heparin was administered to the patient and he was admitted in the coronary care unit. Pulmonary Computed Tomography (CT) angiography showed sub-segmental Pulmonary Thromboendarterectomy (PTE) in the left lung. He had negative cardiac markers and stable vital signs and so full anticoagulation was chosen for his treatment. His clinical course was uneventful and after 10 days of treatment the RV size and function improved significantly. On follow-up after a month he was doing well. Although recent Guidelines of European Society of Cardiology in management of acute PE stated that RiHT, particularly mobile, are associated with a significantly increased early mortality risk in patients with acute PE. Immediate therapy is mandatory, but optimal treatment is controversial in the absence of controlled trials. Thrombolysis and embolectomy are probably both effective while anticoagulation alone seems to be less effective.