Right heart free-floating thrombus after leg injury.

1 of 2 DESCRIPTION A 70-year-old male patient presented to our hospital for investigation of chest pain. He had a history of muscle injury at the right leg during farm work 10 days earlier. Two dimensional (2D) and three (3D) transthoracic echocardiographic examination visualised enlargement of right heart chambers, with a huge wormlike free-fl oating thrombus, approximately 7 cm in length, in them ( fi gure 1A,B ). Due to the increased risk of an acute massive pulmonary embolism a full dose of 40 mg of tenecteplase was administered intravenous bolus without delay. In a new transthoracic echocardiographic examination immediately after the fi brinolysis the thrombus had been completely dissolved ( fi gure 1C ). B-mode and Doppler ultrasonography of the lower limbs demonstrated residual thrombus in the right popliteal vein ( fi gure 1D ) at the region of the muscle injury, while CT scanning revealed evidence of small pulmonary embolism ( fi gure 1E,F ). The patient was treated with unfractionated heparin (UFH) initially, which was starting on the fi rst day. Acenocoumarol was added on the second day and UFH was disjunction when international normalised ratio >2. Based on guidelines, thrombolysis in acute pulmonary embolism is indicated in cases of haemodynamic instability, cardiogenic shock and persistent arterial hypotension. 1 However, in case of free-fl oating right heart thrombus there are insuffi cient data regarding lytic drugs. The widely used thrombolytic agents in pulmonary embolism are urokinase, streptokinase and recombinant tissue plasminogen activator, while with the short acting tenecteplase the experience is limited. This case presents the usefulness of 2D and 3D transthoracic echocardiography in the diagnosis of free-fl oating right heart thrombi and the potential benefi t from the bolus administration of a short acting fi brinolyting agent, in order to eliminate the risk of a massive pulmonary embolism with catastrophic results for the patient.