Thrombus-in-transit involving all four chambers of the heart in a patient presenting with acute pulmonary embolism

A 43-year-old male with history of pulmonary embolism defaulted on anti-coagulation and presented with recurrent massive pulmonary embolism. Echocardiography revealed a serpiginous freely floating right atrial thrombus prolapsing through the tricuspid valve into the right ventricle. Thrombus was also seen crossing the interatrial septum into the left atrium and prolapsing into the left ventricle. Right-sided chambers were dilated with right ventricular dysfunction. Left ventricle was functioning normally. After evaluation by the pulmonary embolism response team, thrombolysis was done with alteplase which resulted in dramatic improvement of the symptoms and complete resolution of the intra-cardiac thrombus. Regular follow-up and counselling are advised henceforth to ensure drug compliance. LEARNING OBJECTIVES: 1. In patients with right heart thrombus crossing an intracardiac communication into left-sided chambers carries an additional risk. 2. Pulmonary embolism response team is essential for clinical decision-making. 3. Echocardiography plays a critical role to diagnose and assess the extent of the intracardiac thrombus and ventricular function. 4. On computed tomography, right ventricular (RV)/left ventricular diameter ratio of >0.9 and the presence of septal bowing signifies the presence of RV strain. 5. Adequate counselling ensuring patient compliance and regular follow up is of utmost importance.