Free-Floating Right Ventricular Thrombus as Assessed by Real-time 3-Dimensional Transesophageal Echocardiography

A 71-year-old woman being treated with predonine at a dose of 10 mg/d for rheumatoid arthritis had a short episode of syncope lasting a couple of minutes. Her physical examination on admission revealed clear consciousness, resting tachycardia of 96 beats per minute, blood pressure of 114/68 mm Hg, jugular venous distention, and edema of the dorsum of the right foot. Electrocardiography revealed sinus tachycardia and right axis deviation. Chest radiography showed no pulmonary congestion. Transthoracic echocardiography showed a moderately dilated right ventricle with impaired right ventricular systolic function containing a large freefloating echogenic mass. There was moderate tricuspid regurgitation with an estimated pulmonary artery pressure of 59/24 mm Hg. Subsequent investigation by real-time 3-dimensional transesophageal echocardiography revealed that the large floating right intraventricular mass was highly mobile (Figure 1A and Video 1) and attached to the chordal structures of the tricuspid valve, which was prolapsing through the pulmonary valve into the main pulmonary artery. The clinical suspicion of pulmonary thromboembolism was subsequently confirmed by lung perfusion scanning. Anticoagulation therapy with intravenous heparin was initiated, and urgent cardiac surgery was performed with complete removal of the thrombus (Figure 1B). Histopathologic examination of the removed material showed findings consistent with a thrombus. Long-term oral anticoagula-