Successful systemic fibrinolysis in pulmonary embolism with a thrombus-in-transit

Right heart thrombus-in-transit with acute pulmonary embolism (PE) is a rare but potentially lethal clinical finding. Optimal management remains controversial, particularly when major contraindications or risk factors coexist. We present a 72-year-old male admitted to the emergency room with leading diagnosis acute coronary syndrome who was later diagnosed with acute PE and a massive, mobile right heart thrombus along with a concomitant ascending aortic aneurysm. Due to high surgical risk, systemic fibrinolysis was performed under close monitoring. Follow-up echocardiography demonstrated complete resolution of the intracardiac thrombus, rapid right ventricular recovery, and an intact thoracic aorta. This case highlights the importance of echocardiography in initial evaluation of patients with acute cardiovascular symptoms and also systemic thrombolysis as a viable, life-saving strategy for right heart thrombosis even in complex clinical scenarios.