A Thief Caught in the Act - Free Floating Venous Thrombus in the Right Heart Associated With Pulmonary Embolism -

cc This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. A 65-year-old, previous healthy woman was referred for evaluation of exertional dyspnea that had developed three days prior. Radical hysterectomy had been done for cervical cancer, followed by reoperation for wound dehiscence 12 days before referral. Lower extremity edema was observed solely on the right side. Transthoracic echocardiography revealed serpentine, free-floating thrombus, starting from the inferior vena cava and extending to the right ventricle (RV) at diastole and the dilated RV showed systolic dysfunction (Fig. 1A, B and C). Computed tomography (CT) showed near total obstruction of pulmonary arteries and deep vein thrombosis of the right femoral vein (Fig. 1D and E). Administration of intravenous heparin with close monitoring was selected as the initial treatment, rather than thrombolysis or surgical embolectomy. This was due to the patient’s stable vital signs, and most importantly, a history of repeated surgical operation and serious wound dehiscence with ongoing infective intraabdominal lymphocele. The thrombus disappeared 4 days later, though pulmonary hypertension remained (Fig. 1F and G). Oral anticoagulation treatment was started and the patient was markedly relieved of dyspnea 14 days later, with significant improvement of RV function (Fig. 1H) and complete resolution of pulmonary thrombus as assessed 4 months later by CT (Fig. 1I). Although the prognosis is more fatal for patients with pulmonary embolism that is associated with right heart thrombus,1) the efficacy of different treatments, including the use of anticoagulants, thrombolytic therapy,2) or surgical embolectomy,3) remains controversial.3)4) In this case, given the patient’s stable vital signs and past medical history, radical thrombolysis or thrombectomy was not performed, and fortunately she had an uncomplicated recovery.