Right Heart Thrombus in Transit With Pulmonary Embolism in the Presence of Intracranial Bleed: A Treatment Dilemma

Abstract

INTRODUCTION: Right heart thrombus in transit (RHTT) is a rare phenomenon complicating acute pulmonary embolism (PE), which is associated with high mortality. There are no clear treatment guidelines currently. We report a case of RHTT managed with heparin alone in a patient with recent craniotomy. CASE PRESENTATION:A 50 year-old man with history of Glioblastoma multiforme status post chemo-radiotherapy, partial resection, and craniotomy one month prior, presented with sudden onset of shortness of breath while undergoing acute rehabilitation. He had tachycardia, hypoxia, and tachypnea with the use of accessory muscles of respiration. Bedside ultrasound revealed dilated right ventricle with a mobile mass in the right atrium, which was confirmed by official echocardiogram. Anticoagulation with unfractionated heparin was started and he was placed on noninvasive ventilation (NIV) for hypoxia. CT brain revealed trace hemorrhage within the right frontal surgical cavity. In light of these new findings detailed discussion was done with the neurosurgeon and the family. It was decided to continue anticoagulation with heparin, as the risk of death from thrombus burden and PE was more than that of the extension of the intracranial hemorrhage. A follow up echocardiogram two days later revealed no right atrial thrombus, and a new thrombus in the right ventricle, which also disappeared after two days. His oxygen requirements gradually improved and he was weaned off. An IVC filter was placed.