Free-floating right heart thrombi in pulmonary embolism: therapeutic options and differential diagnosis

Abstract

Background: There is little published evidence on the treatment of mobile masses in the right heart. We report the clinical courses of three consecutive patients presenting with acute pulmonary embolism and mobile masses in the right heart. History and admission findings: Three women, aged 75, 72 and 52 years, were hospitalized within three months because of dyspnea and suspected pulmonary embolism. Investigations: Transthoracic echocardiography revealed right ventricular dysfunction and highly mobile masses, which were considered as in-transit right heart thrombi in all cases. Treatment and course: All patients received immediate thrombolytic therapy (alteplase). No bleeding complications occurred. Thrombolysis was successful in the first two cases. However, the mass in the right ventricle did not disappear after thrombolysis in the third case and was removed surgically later on. The definite histological diagnosis was a myxoma of the right ventricle. Conclusion: According to literature, in-transit right heart thrombi are a potentially life-threatening complication of pulmonary embolism even in stable patients. Immediate thrombolysis is a valid therapeutic option and was successfully performed in 2 of our 3 patients. However, as case 3 suggests, differential diagnoses concerning mobile masses in the right heart, i.e. cardiac myxoma, should be taken into account and excluded by thoracic computed tomography.