Thrombus in Transit: Key Echocardiography Findings in the ED

A 32-year-old Asian male presented to the ED with a one-day history of mild pleuritic chest pain. He was diagnosed with an acute pulmonary embolus on CT Pulmonary Angiography (CT-PA). Transthoracic echocardiography (TTE) performed at the bedside in the ED demonstrated evidence of right heart strain but, most notably, a highly mobile echogenic thrombus in the right atrium, consistent with a clot-in-transit (CIT). This was not visualized on CT due to the influx of contrast in the heart. Based on this, the patient was transferred to the High Dependency Unit for IV heparin and close monitoring. The following day, he underwent clot retrieval using an Inari Flowtriever under direct TTE guidance. He was discharged on oral anticoagulation four days later and experienced no complications on follow-up. CIT is an important feature of pulmonary embolus to identify, as it can escalate the risk stratification of the patient, and management will need to be altered accordingly.