Background: Right atrial (RA) thrombus associated with pulmonary embolism and paradoxical embolus is an uncommon but potentially life-threatening condition, requiring prompt diagnosis and consideration of multiple different treatment strategies. 

Case summary: A 60-year-old gentleman presented with a paradoxical thromboembolic posterior circulation stroke, incidentally, found to have a large, highly mobile RA thrombus with bilateral sub-massive pulmonary embolism (PE) and extensive deep vein thrombosis (DVT). He underwent successful transcatheter thrombectomy of his PEs on the day of presentation. Subsequently, a second successful thrombectomy to his RA thrombus, PE and DVTs was performed following increase in thrombus burden despite anticoagulation. 

Discussion: This case illustrates transcatheter thrombectomy as a safe alternative with good clinical outcome in the acute management of RA thrombus, when surgical thrombectomy is too high risk and fibrinolysis is contraindicated. 

Take home message: In a setting where an optimal strategy is not clearly defined, management needs to be individualized with a multidisciplinary approach to treatment.

To be updated