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Rare case of a large intracardiac serpiginous thrombus
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  1. Yixin Zhang1,
  2. Kevin Green2,
  3. Stuart Shah3 and
  4. Srinivasan Sattiraju4
  1. 1Internal Medicine, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
  2. 2Pulmonary and Critical Care Medicine, University of Florida Health at Jacksonville, Jacksonville, Florida, USA
  3. 3Pulmonary and Critical Care, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
  4. 4Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, Florida, USA
  1. Correspondence to Dr Yixin Zhang; wendyz0411{at}gmail.com

https://doi.org/10.1136/bcr-2022-250545

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    Description

    A man in his 50s presented to us with worsening fatigue and shortness of breath for 1 month. He recently underwent orthopaedics surgery and has been less active compared with baseline. Upon arrival, he was in obvious respiratory distress. Vital signs at the time showed blood pressure of 104/76 mm Hg, pulse rate of 90 beats per minute and pulse saturation of 92% on room air. The rest of the physical examination is unremarkable. The patient was put on 4 L of nasal cannula with symptomatic improvement. CT showed bilateral subsegmental pulmonary embolism (figure 1). Transthoracic echocardiogram (TTE) revealed a large serpiginous thrombus measuring at least 8 cm in the right atrium, intermittently protruding into the right ventricle (RV) along with severe RV dysfunction (figure 2A, video 1).

    Figure 1
    Figure 1

    CT angiography of the chest showing bilateral subsegmental pulmonary embolism (red arrow).

    Figure 2
    Figure 2

    (A) Off-axis apical four-chamber view showing a serpiginous clot between the right atrium (RA) and right ventricle (RV). (B) Complete resolution of the clot after administration of tissue plasminogen activator. LA, left atrium; LV, left ventricle.

    Video 1

    Disclaimer: this video summarises a scientific article published by BMJ Publishing Group Limited (BMJ). The content of this video has not been peer-reviewed and does not constitute medical advice. Any opinions expressed are solely those of the contributors. Viewers should be aware that professionals in the field may have different opinions. BMJ does not endorse any opinions expressed or recommendations discussed. Viewers should not use the content of the video as the basis for any medical treatment. BMJ disclaims all liability and responsibility arising from any reliance placed on the content.

    The patient was initially evaluated for a thrombectomy, but it was ultimately deferred due to the high motility of his intracardiac clot. We were worried that even gentle manipulation of the thrombus could possibly lead to secondary embolism. Although he was haemodynamically stable at the time, we decided to administer 50 mg of intravenous systemic tissue plasminogen activator (tPA) infused over 2 hours due to the great embolic potential of his clot. Repeat TTE 48 hours after tPA administration showed complete resolution of the clot (figure 2B, video 2). The patient also reported symptomatic relief without any further clinical deterioration. The patient was discharged with rivaroxaban after 5 days of hospital stay. This case provides striking TTE image and video of an exceptionally rare serpiginous clot moving freely between two cardiac chambers. It demonstrated that transthoracic echocardiography remains a valuable diagnostic modality for evaluation in thromboembolic disease and with timely use can be lifesaving.

    Video 2

    Disclaimer: this video summarises a scientific article published by BMJ Publishing Group Limited (BMJ). The content of this video has not been peer-reviewed and does not constitute medical advice. Any opinions expressed are solely those of the contributors. Viewers should be aware that professionals in the field may have different opinions. BMJ does not endorse any opinions expressed or recommendations discussed. Viewers should not use the content of the video as the basis for any medical treatment. BMJ disclaims all liability and responsibility arising from any reliance placed on the content.

    Learning points

    • Choosing the correct treatment modality in patients with intracardiac thrombus (eg, systemic thrombolytics, thrombectomy).

    • Recognising possible fatal complications associated with a highly mobile intracardiac clot.

    • The use of transthoracic echocardiography in thromboembolic disease can be lifesaving.

    Ethics statements

    Patient consent for publication

    Acknowledgments

    The authors acknowledge Hannah Burke, Sonographer for her contribution with echo images.

    Footnotes

    • Contributors YZ drafted the manuscript and actively participated in patient care. KG proofread the final draft and actively participated in patient care. SS proofread and edited the final draft and actively participated in patient care. SS drafted the manuscript and interpreted the diagnostic imaging.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.