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+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).