Thrombus in Transit Captured with POCUS

Dr. Pete Steinmetz is one of the POCUS leaders at McGill University in Montreal. He runs the POCUS program for the med students. Pete and I go way back. We were in the same med school class at McGill…Class of…never the mind the year…it’s not important 😉
Pete sent us this great case! Take it way, Pete!

Case summary:
An 80 y.o. man presented with general deterioration, weight loss, a swollen left leg and episodes of syncope. He complained of weakness, but no chest pain or dyspnea. This fellow was cachectic, but alert and oriented. He was hemodynamically stable with an O2 sat of 94% on room air. He had a mass palpable in the abdomen and a swollen left leg.

On POCUS he had a DVT in the CFV. The liver showed a heterogeneous texture consistent with, and later proven by CT scan, to be liver metastasis. No abdominal mass was appreciated on ultrasound. Then we decided to perform Cardiac POCUS. Here is the patient’s SX view.

The apex was obscured by bowel gas but, as you can see, a thrombus is seen in the right atrium. Here is the A4C view:

The thrombus is in the right atrium and can be seen moving through the tricuspid valve and entering the RV during diastole. Note that there is a communication visible in the interatrial septum, a patent foramen ovale. If the thrombus were to traverse into the left side of heart, a paradoxical embolism would result.

After discussion with the patient and family we opted for palliative care. Both the patient and family were able to view the images. These real-time images helped them clearly understand the clinical situation.