Pulmonary thromboembolic disease is a common and often fatal disorder that can be difficult to diagnose. It has been recognized that patients with massive pulmonary emboli presenting with hypotension, right ventricular dysfunction, and an elevated brain natriuretic peptide (BNP) level have an especially high mortality. Rarely, a thromboembolus is visualized en route through the right heart with imaging modalities such as echocardiography. The largest case series of this phenomenon reported to date calculated an in-hospital mortality rate of 45%, half of whom died in the first 24 hours after presentation. We present a case of an 81-year-old man who presented with acute dyspnea and hypotension and was found to have a dilated hypokinetic right ventricle, elevated pulmonary arterial pressure, and a large worm-like free-floating thromboembolus in the right heart. He was treated with an intravenous infusion of alteplase and responded well with resolution of hypotension and hypoxemia. A repeat echocardiogram performed 30 minutes into the infusion failed to demonstrate any residual intracardiac thromboemboli and noted significant improvement in pulmonary arterial pressure. This case demonstrates the efficacy of treating massive pulmonary emboli with free-floating thromboemboli in the right heart with thrombolytic therapy.
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