title: Large embolus in transit - an unresolved therapeutic dilemma (case report and review of literature).
abstract: Floating right heart thrombus, also known as "emboli in transit" is a potentially fatal condition, of varying etiology and usually coexisting with massive pulmonary embolism. Although the mortality rate is as high as 40%, there are no established therapeutic guidelines. A case is presented of an 84 year old female with a history of colon cancer and coronary artery disease who presented with sudden onset unresponsiveness. She was intubated in the ED and started on intravenous pressor support. A free floating large right ventricular thrombus and dilated right ventricle were noted on transthoracic echocardiogram (TTE). She was managed medically with good short term outcome. Floating right heart thrombus is a rare occurrence. Recognition of signs and symptoms along with early TTE is critical for diagnosis and consideration of treatment modality. The existing literature does not offer a clear consensus for management of pulmonary embolism with co-existing mobile intra-cardiac thrombus. Choice of treatment is crucial and should be considered on a case-by-case basis after careful assessment of indications, contraindications, risks and benefits.
authors.affiliation: Department of Medicine, Staten Island University Hospital, 475 Seaview Ave., Staten Island, NY 10305, USA. Electronic address: vratika.agarwal@gmail.com.
authors.forename: Vratika
authors.initials: V
authors.lastname: Agarwal
authors.affiliation: Department of Medicine, Staten Island University Hospital, 475 Seaview Ave., Staten Island, NY 10305, USA.
authors.forename: Nikhil
authors.initials: N
authors.lastname: Nalluri
authors.affiliation: Department of Cardiothoracic Research, Staten Island University Hospital, Staten Island, NY, USA.
authors.forename: Masood A
authors.initials: MA
authors.lastname: Shariff
authors.affiliation: Department of Cardiology, Staten Island University Hospital, Staten Island, NY, USA.
authors.forename: Muhammad S
authors.initials: MS
authors.lastname: Akhtar
authors.affiliation: Department of Cardiology, Staten Island University Hospital, Staten Island, NY, USA.
authors.forename: Yefim
authors.initials: Y
authors.lastname: Olkovsky
authors.affiliation: Department of Critical Care Medicine, Staten Island University Hospital, Staten Island, NY, USA.
authors.forename: Paul E
authors.initials: PE
authors.lastname: Kitsis
authors.affiliation: Department of Cardiothoracic Surgery, Staten Island University Hospital, Staten Island, NY, USA.
authors.forename: John P
authors.initials: JP
authors.lastname: Nabagiez
mesh_terms: D000369:Aged, 80 and over; D004452:Echocardiography; D005260:Female; D006331:Heart Diseases / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000601:surgery; D006801:Humans; D015912:Thrombolytic Therapy; D013927:Thrombosis / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000601:surgery
keywords: Critical care; Right heart thrombus; Thrombolytic therapy; Transthoracic echocardiography