Intracavitary thrombus in the left ventricle and high-risk pulmonary embolism. A case report

Massive pulmonary embolism (PE) is a life-threatening condition typically requiring systemic thrombolysis. The presence of a left ventricular (LV) thrombus represents a relative contraindication due to the high risk of systemic embolization, requiring individualized management. We present a 73-year-old woman with a history of non-Hodgkin lymphoma in remission, severe LV dysfunction from chemotherapy and radiotherapy, permanent atrial fibrillation under apixaban, and stage 3 chronic kidney disease. She presented with progressive dyspnea, edema, and syncope. On admission, she presented with cardiogenic shock. Imaging confirmed massive bilateral PE and an LV intracavitary thrombus. Thrombolysis was contraindicated due to multiple high-risk factors: LV thrombus, ongoing anticoagulation, advanced age, and renal dysfunction. Management consisted of therapeutic anticoagulation with unfractionated heparin, vasopressor and inotropic support, and close monitoring, showing progressive clinical improvement. This case highlights the complexity of managing massive PE in cardio-oncology patients and underscores the need for individualized strategies when thrombolysis poses unacceptable risks.