Catheter-directed thrombolysis for giant right atrial thrombus.

Giant right atrial thrombus in association with a medical device is rare1,2 but when present poses the threat of massive pulmonary embolism. Surgical resection, catheter embolectomy, and thrombolysis are the principal options for management. We present the case of a 60-year-old man with bilateral pulmonary embolism and a 6-cm right atrial thrombus adherent to an implantable cardioverter-defibrillator (ICD) wire. We treated him successfully with a prolonged intravenous infusion of catheter-directed, low-dose tissue plasminogen activator therapy. Two weeks before admission, he had an acute myocardial infarction and had severely occlusive atherosclerotic coronary disease on coronary angiography. However, a culprit thrombotic lesion to account for the acute myocardial infarction could not be identified. Four days later, the patient survived an in-hospital ventricular fibrillation–induced cardiac arrest, after which an ICD was placed. He was discharged on aspirin 325 mg daily, clopidogrel 75 mg daily, and warfarin 5 mg daily but was nonadherent to this medical regimen. The patient was admitted to our hospital 4 days after prior hospital discharge with a chief complaint of sudden onset of shortness of breath. The physical examination revealed a man in mild distress with a blood pressure of 118/62 mm Hg, heart rate of 103 bpm, respiratory rate of 22 breaths/min, and peripheral blood oxygen saturation level of 95% on 3 L of oxygen per nasal cannula. He had a right ventricular heave and an accentuated pulmonary component of the second heart