# Right Heart Transvalvular Embolus with High Risk Pulmonary Embolism in a Recently Hospitalized Patient: A Case Report of a Therapeutic Challenge

## TL;DR

A rare case of a right heart transvalvular embolus with severe pulmonary embolism was successfully treated with surgical embolectomy and IVC filter placement.

## Contribution

This case highlights the importance of bedside echocardiography and surgical intervention in managing rare and high-risk pulmonary embolism.

## Key findings

- A mobile echodensity attached to the tricuspid valve was detected via echocardiogram.
- Surgical embolectomy under cardiopulmonary bypass successfully removed the embolus.
- The patient had a favorable outcome after treatment and was discharged on Coumadin.

## Abstract

Thrombus-in-transit is not uncommon in pulmonary embolism but Right Heart Transvalvular Embolus (RHTVE) complicating this is rare. A 54-year-old obese male with recent hospitalization presented with severe dyspnea and collapse. Initial investigations revealed elevated d-dimer and troponin. CTA showed saddle pulmonary embolus and bedside echocardiogram revealed right ventricular (RV) pressure overload and dilatation (RV > 41 mm), McConnell's sign, and mobile echodensity attached to tricuspid valve. Patient was immediately resuscitated and promptly transferred for surgical embolectomy under cardiopulmonary bypass. A long segment of embolus traversing through the tricuspid valve and extensive bilateral pulmonary artery embolus were removed. IVC filter was placed for a persistent right lower extremity DVT. Hypercoagulable work-up was negative. Patient continued to do well after discharge on Coumadin. Open embolectomy offers great promises where there is no consensus in optimal management approach in such patients. Bedside echocardiogram is vital in risk stratification and deciding choice of advanced PE treatment.