Pulmonary thromboembolism caused by a giant free-floating right atrial thrombus

A 71-years-old man patient was admitted to our cardiology department with progressive dyspnea and bilaterally legs pain. His medical history unremarkable except bilateral deep venous thrombosis was diagnosed two days ago. Physical examination showed a respiratory rate of 32, pulse of 123 (irregular) and blood pressure of 100/70 mmHg. In addition, there were swelling and redness of the bilaterally legs. Electrocardiography revealed atrial fibrillation with ventricular rate of 130/minute, incomplete right bundle branch block and nonspesific ST segment and T-wave abnormalities. Transthoracic echocardiography was immediately performed and detected a giant, mobile, free-floating thrombus in the right atrium sometimes crossing through the tricuspid valve to the right ventricle (Fig. 1 and 2). There were severe tricuspid regurgitation and dilated right cardiac chambers, systolic pulmonary arterial pressure of 65 mmHg and normal left ventricular systolic functions. Clinical and echocardiographic findings of the patient were correlated with acute pulmonary embolism. Therefore, we immediately decided to administer thrombolytic therapy but hemodynamic status of the patient deteriorated in a few minutes and the patient was lost due to cardiopulmonary arrest.