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Despite lack of concrete evidence, right ventricular thrombus is generally considered to be a contraindication for intracardiac lead placement. We present a case of successful placement of a right ventricular defibrillator lead and left bundle branch pacing lead and atrioventricular node ablation in a patient with chronic right ventricle thrombus.

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Right ventricular thrombi (RVTs) have been almost exclusively studied in patients with pulmonary embolism (PE). The implications of an isolated RVT, a finding typically encountered on transthoracic echocardiography (TTE), are lacking. In this study, we sought to identify the echocardiographic and clinical features associated with the presence of RVTs. Between 1998 and 2023, 138 patients with RVT documented on TTE were retrospectively identified. Demographic data, presence of intracardiac devices, hypercoagulable conditions, history of deep vein thrombosis (DVT), PE, and/or left ventricular thrombus were abstracted from electronic chart review. Measurements of right and left ventricular size, and function were performed on TTE. Of the total population of patients with RVT, <1/2 had intracardiac devices, 29% had a documented hypercoagulable state (e.g., cancer or a clotting disorder). Most patients had dilated (77%) and dysfunctional (72%) right ventricles. Approximately 50% of RVTs were discovered in nonstandard imaging planes, suggesting that the presence of RVT is likely underestimated in clinical practice. Of those evaluated for PE, 80% had PE. Of those evaluated for DVT, 53% had DVT. In conclusion, further investigations are warranted to better guide when to investigate the right ventricle for RVTs on TTE and the impact of RVTs on patient outcomes.

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An 86-year-old female on dialysis experienced a decrease in blood pressure and worsening of her respiratory condition during dialysis, for which she visited our emergency unit. She was admitted to our Department of Cardiology with a diagnosis of acute myocardial infarction complicated with heart failure because of anterior wall of left ventricular dysfunction, positive troponin T levels and negative T wave on a precordial lead electrocardiogram. On the same day, she underwent coronary angiography and stenting at left anterior descending artery #7 with 99% stenosis. She also showed an elevated D-dimer level on admission, and contrast-enhanced computed tomography (CT) was performed the day after admission, considering the likelihood of respiratory failure due to pulmonary thromboembolism. However, the findings were negative. On the 4th day of hospitalization, she showed marked hypoxemia. Her D-dimer level was further elevated, and when she underwent enhanced CT again, there was no evidence of deep vein thrombosis, but thrombus in the pulmonary artery and apex of right ventricle was noted. She was therefore diagnosed with acute pulmonary embolism due to thrombosis from the right ventricle rather than from a deep vein. She rapidly received anticoagulant therapy and non-invasive positive pressure ventilation therapy for respiratory failure, but she entered cardiopulmonary arrest and quickly died. She was suspected to have been complicated with a right ventricular infarction and an acute anterior wall myocardial infarction, resulting in a large thrombus along the apex of the right ventricle. This case of both myocardial infarction and pulmonary embolism is very rare, and we report it here with consideration.

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An intracardiac thrombus may develop as a consequence of myocarditis, and in rare cases, a dominantly right ventricular thrombus develops, which may impair cardiac function and even cause life-threatening cardiovascular events. We report a 24-year-old man presented with recurrent episodes of palpitation and precordial discomfort after catching a cold 2 months ago. Transthoracic echocardiography (TTE) and computed tomography pulmonary angiogram (CTPA) revealed a mass attached to the apex of the right ventricle and extensive bilateral pulmonary artery emboli. There was no indication where the thrombi originated from in this young patient without any underlying disease except myocarditis. Pulmonary endarterectomy and embolectomy of pulmonary arteries and right ventricle were performed. Postoperative pathological results confirmed the presence of fibrinous necrosis and hemosiderin deposition. The formation of an intraventricular thrombus is closely related to myocarditis, which can affect individuals of all ages, but especially young people. Thus, patients with myocarditis should be closely monitored and followed up because of the increased risk of extensive thrombosis.

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Hypercoagulability in coronavirus disease 2019 infection is already a known fact. But in this article, we have discussed a unique case where the patient had suffered from relapsing thrombus formation. This report describes the case of a patient who presented with chronic coronavirus disease 2019-induced recurrent thrombi refractory to multiple antithrombotic regimens because of multiple recurrent inflammatory flares without any evidence of chronic persistent viral infection. The patient was treated with anticoagulation and anti-inflammatory medications. Still, he had repeated episodes of right ventricular thrombus. Coronavirus disease 2019 can provoke a severe relapsing hypercoagulable state without evidence of persisting viral infection. Rebound inflammatory flares rather than viral recurrence may play a trigger.

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Coronavirus disease 2019 (COVID-19) is a viral respiratory disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The respiratory system is the main target of the virus; however, apart from lung disease, a relatively large proportion of patients develop thrombosis as well. We present the case of a 19-year-old male who was admitted after contracting community-acquired right-sided pneumonia. The patient had a history of COVID-19 infection four weeks before admission. The echocardiographic assessment revealed a 16 x 6-mm right ventricular (RV) thrombus. He underwent a cardiovascular magnetic resonance (CMR) study, which confirmed the findings. After ruling out the most common causes of hypercoagulability, COVID-19 was judged to be the cause of the thrombus. The patient was treated with warfarin. Follow-up imaging with echocardiography and CMR six months later revealed complete resolution of the thrombus. Hypercoagulability is a major complication of COVID-19 and in situ thrombosis can occur both in the arterial and venous circulation. The recognition of intracardiac thrombi even in low-risk patients with a history of COVID-19 infection and the immediate initiation of antithrombotic treatment to minimize the risk of embolization is of paramount importance. Advanced imaging techniques are often required to establish the diagnosis of this condition.

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Massive pulmonary embolism (PE) combined with right atrial (RA) thrombus is associated with significant mortality. Hemodynamic collapses, which can manifest as hypotension, severe dyspnea; cyanosis, syncope, shock, and right ventricular heart failure are the hallmark of massive PE. Moreover, hemodynamic collapse can be the earliest clinical presentation and the most common cause of death in the first days. Although fibrinolytic therapy has contraindications; exclusion is necessary to minimize bleeding risk, but it can be lifesaving and prevent complications such as shock, right ventricular heart failure, and multi-system organ failure. Here, we report a 70-year-old woman who has an atypical presentation of sudden onset of a persistent hiccup for 8 hours diagnosed with massive pulmonary embolism with multiple free floating thromboses in the right atrial and right ventricle which has been successfully treated with systemic fibrinolytic. Furthermore, the patient was given a Tenecteplase as a last resort to save her life due to the unavailability of the catheter or surgical embolectomy besides an absolute contraindication for thrombolytic.

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Intracardiac thrombus is often seen as a complication of ischemic heart disease (IHD) and non-ischemia cardiomyopathies (NICM). The advancements in imaging modalities and therapeutic options have helped reduce the complications arising from ventricular thrombi, such as systemic embolization. Here we present two cases of intracardiac thrombus associated with coronavirus disease (COVID) 19, one with an apical thrombus in the left ventricle and the other with a thrombus in the right ventricle adjacent to chordae tendinae. The effects of covid-19 on the cardiovascular system are yet to be thoroughly evaluated. Venous and arterial thrombosis is commonly associated with COVID-19 but in situ detection of intracardiac thrombus has not been very frequently reported. Intracardiac thrombus and embolization pose a very high risk of complications in COVID-19. The coronavirus pandemic caused by SARS-CoV-2 during 2019-2021 has caused several deaths and has resulted in many long-term consequences, many of which remain unclear. In-hospital complications from COVID-19 are better reported due to constant monitoring. The ongoing, late, and chronic complications arising from COVID-19 require more vigilant case-by-case screening and surveillance.

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Sinus of Valsalva aneurysms are abnormal bulges of the aortic root caused by a tissue deficiency resulting in an enlargement of the aortic root in the area between the aortic annulus and the sinotubular junction. Frequently, sinus of Valsalva aneurysms are asymptomatic. However, sinus of Valsalva aneurysms can also be potentially fatal due to their risk of rupture. We present a case of a 49-year old asymptomatic male patient with a rare image of a sinus of Valsalva aneurysm of the non-coronary cusp which was initially mistaken for a right ventricular thrombus. Surgical repair of the sinus of Valsalva aneurysm was eventually achieved by a valve sparing root replacement and the patient was discharged 7 days after surgery. This case report shows that sinus of Valsalva aneurysms are vulnerable to misdiagnosis when it is not initially suspected. Because of the potential fatality of this phenomenon we would like to underline the necessary vigilance in the diagnostic process, as sinus of Valsalva aneurysms can be missed when the physician is not aware of this potential rare diagnosis.

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Inflammation related to coronavirus disease (COVID)-19 can promote a pro-thrombotic process and subsequent thrombosis. We report a confirmed COVID-19 case in a 51-year-old patient who presented with chest pain and severe hypoxemia. Although the right heart chambers are unusual locations for a thrombus, an echocardiogram demonstrated a large mobile right ventricular thrombus protruding into the right ventricle outflow tract. A computed tomography angiogram and cardiac magnetic resonance image showed the extension of the thrombus into the pulmonary trunk. A continuous intravenous unfractionated heparin infusion resulted in a dramatic clinical and echocardiographic improvement. .

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BACKGROUND: Intraventricular masses are a relatively rare condition ranging from asymptomatic to potentially life-threatening situations. CASE SUMMARY: Herein, we report a case of a 49-year-old woman under investigation for a massive right ventricular (RV) mass who underwent complete investigation for possible differential diagnosis, in the suspect of RV tumour. Multimodality imaging with cardiac computed tomography and magnetic resonance imaging showed the presence of a massive thrombus partially obliterating the right ventricle. Surgical removal of the mass showed a large area of stratified thrombosis with an underlying area of endocardial fibrosis. The patient has been then discharged in good clinical condition and with lifetime oral anticoagulation. DISCUSSION: Massive RV thrombosis is a rare yet potentially fatal condition. Invasive management is preferable and lifetime anticoagulation is required to reduce possible downstream thrombotic complications.

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Ventricular thrombus is an uncommon, severe condition with high morbidity and mortality. Simultaneous left and right ventricular thrombi caused by lupus myocardiopathy have not been previously reported in the literature. This case presents a 42-year-old woman who has bilateral ventricular thrombi with reduced left ventricular ejection fraction (35.4%) and acute kidney injury. Pro-brain natriuretic peptide was >35000 pg/mL. Systemic lupus erythematosus was confirmed based on multiorgan injuries including malar rash, anemia, renal injury, positive antinuclear, anti-Smith antibodies, and decreased complements. Renal biopsy revealed lupus nephritis class III + V. Low molecular weight heparin, steroids, and mycophenolate mofetil were initiated, after which the patient experienced transient numbness in the right limbs and hemoptysis. She then recovered quickly and improved significantly with recovery of left ventricular systolic function (left ventricular ejection fraction 46%) and the eventual disappearance of thrombi. Simultaneous left and right ventricular thrombi are rare but life-threatening condition, prompting consideration of myocardiopathy caused by autoimmune diseases such as lupus. Timely treatment with immunosuppressants and anticoagulants may resolve the thrombi and improve cardiac function.

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BACKGROUND: SARS-CoV-2 is a novel viral illness originating out of Wuhan China in late 2019. This global pandemic has infected nearly 3 million people and accounted for 200 000 deaths worldwide, with those numbers still climbing. CASE SUMMARY: We present a 54-year-old patient who developed respiratory failure requiring endotracheal intubation from her infection with SARS-CoV-2. This patient was subsequently found to have a right ventricular thrombus and bilateral pulmonary emboli, likely contributing to her respiratory status. On the 14th day of hospitalization, the patient was successfully extubated, and 5 days later was discharged to the rehabilitation unit. DISCUSSION: SARS-CoV-2 presents primarily with pulmonary symptoms; however, many patients, particularly those who are severely ill, exhibit adverse events related to hypercoagulability. The exact mechanism explaining this hypercoagulable state has yet to be elucidated, but these thrombotic events have been linked to the increased inflammation caused by SARS-CoV-2. This novel viral illness is still largely misunderstood, but the hypercoagulable state, seen in severely ill patients, appears to play a major role in disease progression and prognosis.

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The course of dermatomyositis (DM) can be complicated by multi-organ failure, by complex pathophysiological mechanisms involving autoantibodies. Pulmonary complications are the leading cause of mortality, accounting for 30% of deaths. There is a strong association between DM and interstitial lung disease (ILD); clinically amyopathic dermatomyositis (CADM) has a stronger association with ILD as compared to a classic form of DM. ILD can be in the form of fibrosing alveolitis, interstitial pneumonia, and desquamative interstitial pneumonia or diffuse alveolar hemorrhage. Autoantibodies linked to ILD are anti Jo-1, PL12, PL7, EJ, and OJ and anti Mi 2. Our case describes a fifty-three years old woman who presented with symptoms of lower respiratory tract infection, diagnosed with CADM based on typical skin rash and polyarthritis and anti-CADM 140 antibodies. Systemic steroid therapy (initiated after ruling out sepsis) failed to provide improvement. The medical course was complicated by multisystem involvement (respiratory failure, cerebral edema, renal failure, coagulopathy, hepatic failure, and thromboembolism). Transthoracic echocardiogram revealed thrombus in the right ventricle, which was the result of the prothrombotic state, and the patient expired on day tenth of hospitalization. Our case describes a unique case of right ventricular thrombosis secondary to macrophage activation syndrome (MAS).

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We report what appears to be the first case of biopsy-proven nonvalvular endocarditis with biventricular apical infected thrombi. A 47-year-old man presented with hypoxic respiratory failure from a multilobar pneumonia due to methicillin-resistant Staphylococcus aureus (MRSA). Transthoracic echocardiography and cardiac magnetic resonance imaging revealed biventricular apical masses suggestive of nonvalvular endocarditis with infected thrombi. Given concern for ongoing septic embolization to the lungs and brain despite appropriate antimicrobial therapy, the masses were surgically resected. Culture and histopathology confirmed MRSA-positive infected thrombi. In this case report, we highlight the differential diagnosis of apical masses and the role of multimodality imaging.

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The new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), that causes the highly contagious coronavirus disease 2019 (COVID-19) has led to an unprecedented global health crisis. Infected patients have been shown to trigger a heightened inflammatory response, increasing thrombotic risk. We report the case of a polymerase chain reaction (PCR)-confirmed COVID-19 in a Hispanic male with no past medical history who presented to the ED with upper respiratory tract symptoms including shortness of breath and cough, requiring continuous positive airway pressure (CPAP) therapy. He was found to have a right ventricular thrombus (RVT) and bilateral deep vein thrombosis (DVT) on the day of admission, which were detected on transthoracic echocardiogram and duplex venous ultrasound, respectively. The patient was started on therapeutic enoxaparin sodium, which led to an improvement in oxygenation, and he was eventually downgraded to the medical floors for further management.

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BACKGROUND: COVID-19 is a novel disease that has been associated with changes in haemostasis and increased risk of thrombosis, especially in patients who are critically ill. CASE SUMMARY: a 71-year-old patient presented to the emergency department with acute respiratory failure. The patient had been discharged from the hospital 1 day before, after apparent recovery of a proven COVID-19 infection. Relevant medical history reports polycythemia vera. The diagnostic work-up included a CT-scan of the thorax, revealing bilateral sub-segmental pulmonary embolism. An echocardiogram showed a dilated right ventricle with poor systolic function and a large multi-lobar thrombus. Forty-eight hours after initiation of treatment with therapeutic anticoagulation the thrombus was no longer seen on the echocardiogram. DISCUSSION: This case confirms the high risk of thrombosis in COVID-19 infection as has been described in recent literature. It demonstrates the severity of the coagulopathy given the presence of both bilateral sub-segmental pulmonary embolism and right ventricular thrombus, despite treatment with prophylactic anticoagulation. Remarkable in this case is the fact that the patient had a myeloproliferative neoplasm (polycythaemia vera). This is associated with an increased risk of thrombosis, especially in the presence of erythrocytosis, leucocytosis, and/or inflammation.

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Left ventricular (LV) thrombus formation is a well-known complication of acute myocardial infarction (AMI) and is reported to occur in 5-8% of patients who have anterior or apical myocardial infarction. However, right ventricular (RV) thrombus has not previously been reported after AMI. We describe a 54-year-old woman who presented with an ST-elevation myocardial infarction due to occlusion of the distal left anterior descending artery, which wrapped around the apex and led to simultaneous LV and RV apical thrombi. .

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We report the case of a 71-year-old woman diagnosed with recent inferior myocardial infarction complicated with right ventricular infarction and a right ventricular thrombus. Three-dimensional transthoracic echocardiography, contrast-enhanced computed tomography, and cardiac magnetic resonance imaging clearly detected a thrombus. We consider cases with a recent right ventricular infarction to require assessment for thrombus formations in the right ventricle. Fortunately, vigorous anticoagulation therapy resolved the thrombi in both the right ventricle and right coronary artery.

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