#FridayImageChallenge

ANSWER: You were correct! The thrombus is in the RA. There is a large free floating thrombus in Right Atrium. Left ventricle ejection fraction is 202-25% with severely depressed RV function. Bi-atrial enlargement with RV dilation. Example apical 4 chamber view on TTE shown below.

4_chamber

Quick Learning Points:
Right sided heart thrombi (RHTh) in 2 types:
– Type A thrombi: worm-like shape, extremely mobile and likely arising from lower-limb veins–> mortality of 28-44%
– Type B thrombi attach to the atrial or ventricular wall indicating that they are probably of local origin. –> mortality of 4% (lower risk than Type A)
* Either can obstruct Right Ventricle filling + emptying or migrate to pulmonary arteries.

Surgical thromboembolectomy has been the treatment of choice in the past, however with RCT lacking – many have presented prospective studies showing good outcome + rapid improvement with t-PA (classically indicated for proven PE w/ cardiogenic shock). Heparin alone may not be adequate as some studies have shown. Catheter-based interventions also an option for those unable to undergo surgery or t-PA.

A Quick Read on the Topic:
http://content.onlinejacc.org/article.aspx?articleid=1132395

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64 year old male smoker, no history of COPD or CHF who presented with 3 days exertional dyspnea and pleuritic chest pain. Echo is done and what do we see?