P235 A happy ending for a dancing thrombus on the right atrium

Abstract A 62-year-old male, was admitted in the emergency department with chest discomfort and dyspnea for the last 2 days; he also referred pain on the right leg. He had been submitted to prostatic surgery 1 month before and since then he reduced is usual physical activity. At admission he was normotensive, with sinus tachycardia, with elevated D-Dimers and hypoxemia and hypocapnia on arterial blood gas analysis. Transthoracic echocardiogram (TTE) was performed and it showed dilation of right ventricle with diastolic left ventricular "D-shape" compatible with right ventricle pressure overload. Furthermore, it was visible a large and filiform thrombus on the right atrium, causing procidency into the right ventricle through the tricuspid valve during diastole (image top-left and top-right). Patient was hemodynamically stable at that time, and the case was promptly discussed with cardiothoracic surgery. The decision was to adopt a conservative strategy, and non-fractioned heparin (NFH) perfusion was initiated accordingly to local protocol. Patient remained hemodynamically stable, and, after 24h of treatment with NFH echocardiographic re-evaluation showed disappearance of the thrombus previously seen of the right chambers (image bottom-left). Angio-TC scan of thorax performed at that time showed extensive bilateral pulmonary thromboembolism, but with normal perfusion of the pulmonary artery trunk and both right and left pulmonary arteries. After 48h of NFH the patient started oral anticoagulation. The rest of the admission was unremarkable apart from a respiratory tract infection successfully treated with piperacillin-tazobactam. Pre-discharge TTE performed 12 days after admission showed no dilation of the right ventricle, with normal systolic function (image bottom-right), as well as no evidence of pulmonary arterial hypertension. Discussion Large right atrial thrombus in the setting of PTE is a clinical situation in which there is no consensus regarding clinical management. In most cases, management is dictated by haemodynamic status of the patient. In the setting of a hemodynamically stable patient, systemic anticoagulation can be an option. Surgery, fibrinolysis and percutaneous aspiration have also been advocated. Successful treatment of right heart thrombus with anticoagulation alone has been reported, but there are also reports of unsuccess with that strategy. This is a case of a successful treatment with anticoagulation alone and so, we currently consider that the choice of treatment strategy based on hemodynamic status continues to be the wisest strategy to adopt. Abstract P235 Figure. Thrombus before and after