Submassive pulmonary embolism with a right heart thrombus

A 49-year-old woman presented to the hospital with shortness of breath 2 weeks after a left total hip replacement. She was found to have a submassive pulmonary embolism (PE), with her case complicated by the detection of a large mobile clot in transit extending through a patent foramen ovale between the right and left atria. The presence of this free-floating right heart thrombus (FFRHT) increases her risks of stroke and mortality, yet the optimal approach to her treatment was unclear. Ultimately, intravenous tissue plasminogen activator was administered with resolution of the clot. Treatment was complicated by haemodynamically insignificant bleeding at the site of recent surgery. Herein, we further discuss the implications and treatment options for patients with an FFRHT in the setting of an acute PE.