A 52-year-old man (body surface area: 1.3 m2) known to have dilated cardiomyopathy (DCM), was admitted for worsening heart failure (NYHA class IV).
He presented with a 5-month history of cough, progressive dyspnoea, orthopnea and recurrent upper abdominal pain started from 2 months ago.
On examination his vital signs were body temperature 37°C, blood pressure 80/40 mmHg, respiratory rate 24 breaths per minute, and electrocardiogram showed atrial fibrillation with heart rate 50 beats per minute.
Physical examination revealed the jugular venous distension, significant tender hepatomegaly and bilateral pitting edema at lower limbs.
Laboratory tests showed elevated pro-NT brain natriuretic peptide of 22145 pg/ml (normal 0 to 227 pg/ml) and unremarkable D-dimer.
X-ray and computed tomography of the chest demonstrated consolidation of bilateral lower lobes with pleural effusion, while his venous Doppler of lower extremities was normal.
Based on his clinical condition, echocardiography was immediately inserted.
There were severe dilated cardiac chambers, especially enlargement of the left ventricle (LV) (58 mm/m2) with spherical shape, decreased wall thickness, impaired ejection fraction 22% and severe mitral regurgitation on two-dimensional transthoracic echocardiography (2DTTE).
Parasternal short axis and subxyphoid view (Figure ​1) showed the mobile right atrial mass highly suspicious of a thrombus traversing the right atrial cavity during the cardiac cycle accompanying with free-floating small parts of the thrombi.
Real-time three dimensional transthoracic echocardiography (RT-3DTTE) was performed to further confirm the nature of mass.
It showed a highly mobile thrombus, irregular in contour, measured 2.6 × 1.0 cm which floating around the orifice of inferior vena cava and protruding into the right atrial cavity (Figure ​2).
In addition, RT-3DTTE evaluated right ventricle (RV) systolic dysfunction with ejection fraction 15.7% (Figure ​3).
He was maintained on digoxin, spironolactone, furosemide, sotalol and dopamine.
At the same time therapeutic anticoagulation was started with low-molecular-weight heparin and warfarin.
The patient had an uneventful hospital course and one week follow-up echocardiography confirmed adequate removal of the thrombus (Figures 4A and ​4B).