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A 55-year-old male was admitted to the cardiology department because of progressive fatigue and exercise intolerance. The patient's previous history included a dualchamber pacemaker implantation 7 years before as a result of bradycardia-tachycardia syndrome and inferior myocardial infarction 6 years ago, which resulted in left ventricular systolic dysfunction (ejection fraction of 30% on echocardiography and chronic total occlusion of the right coronary artery on coronary angiography). As a result of paroxysmal atrial fibrillation, the pacemaker had previously been switched to VVI mode, and coumadin therapy had been continued for a few years. Most recently the level of anticoagulation was unsatisfactory with the International Normalized Ratio value of 1.3. On admission, echocardiography revealed a large spherical thrombus (Ϸ33 mm in diameter) attached to the ventricular lead of the pacemaker (Figure 1, Movie I). The mass was highly mobile and protruded from the right atrium through the tricuspid valve in diastole, with no obstruction to flow (Figure 2, Movies II and III). Taking into account the patient's preference, thrombolytic therapy was given. After completion of the drug regimen, echocardiography showed the absence of the thrombus in the right atrium and normal pulmonary artery pressure (Figures 3 and 4, Movie IV). However, the patient developed right pleural pain, a nonproductive cough, and fever. Multislice computed tomography with a 64-slice scanner was performed, which showed an embolus to the distal right pulmonary artery of the 10th segment ( Figure 5, Movie V). The patient received a second course of thrombolytic therapy, which resulted in substantial clinical improvement. After the resumption of effective coumadin treatment, the patient was discharged home. DisclosuresNone. The online-only Data Supplement, which consists of movies, can be found at http://circ.ahajournals.org/cgi/content/full/113/6/e646/DC1.

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