Detection of right atrial thrombus in a woman with pulmonary embolism and right heart compromise by bedside echocardiography

A 59-year-old female with a history of stage IV lung adenocarcinoma presented with worsening shortness of breath and cough over several weeks. She was tachycardic, hypotensive, and tachypneic. Portable chest x-ray suggested bilateral pleural effusions and computed tomography angiography (CTA) revealed bilateral pulmonary emboli (PE) with suspected right heart strain. Upon admission to the medical intensive care unit for treatment of PE, bedside echocardiography was performed to direct management. Indicators of cor pulmonale and right heart strain were apparent including right ventricle dilation, reduced tricuspid systolic excursion, and a deformed left ventricle with “D sign”. Most notably, a right atrial thrombus was detected, a finding not initially seen on CTA. Ultimately, prompt detection of the effects on the right ventricle by bedside echocardiography directed the next step in this patient's clinical course without delay.