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Main pulmonary artery thrombus.

to our echocardiography department for transthoracic echo evaluation of recurrent episodes of syncope and haemodynamic instability during the previous 24 hours. Her medical history included cholecystectomy, thrombophlebitis of the lower extremities, two episodes of pulmonary embolism, and arterial and pulmonary hypertension. During this current admission in the internal medicine clinic of our hospital, the patient was diagnosed as having distal choledochal duct stenosis highly suggestive of cholangeocarcinoma and had been treated for repeated episodes of cholangitis. Physical examination revealed a patient who was lethargic, tachypnoeic, tachycardiac, with low blood pressure, distended neck veins and a grade 4/6 systolic murmur at the lower left sternal border. The electrocardiogram was indicative of pulmonary embolism, presenting sinus tachycardia with right bundle branch block and an sI qIII TIII pattern that were absent on admission. The echocardiographic examination revealed the presence of a large mass in the main pulmonary artery, just above the leaflets of the pulmonary valve, that was obstructing pulmonary blood flow (Figure 1). The mass was immobile, with irregular borders and a non-homogeneous structure consistent with thrombus. The right ventricle was dilated with depressed contractility. The maximum velocity of the tricuspid valve regurgitation jet was 315 cm/s, which represented a gradient between right ventricle and right atrium of 40 mmHg (Figure 2). The inferior vena cava and hepatic veins were dilated and there was no collapse with inspiration, while left ventricular function was normal. In addition to the pulmonary artery obstruction as a cause of the significant haemodynamic instability, the diagnosis of pulmonary embolism could not be excluded. The patient was transferred to the cardiology clinic, where she was treated with supplemental O2, fluid administration, and subcutaneous injections of low molecular weight heparin, in addition to her initial treatment. Alternative therapeutic strategies, such as thrombolysis or thrombectomy had relative contraindications because of the active bleeding in the choledochal duct stenotic lesion with a high suspicion of cholangeocarcinoma. During the following days, the patient showed progressive clinical improvement. Subsequent transthoracic echo studies performed five days and two weeks after the initial evaluation revealed a gradual decrease (Figure 3) and complete disappearance (Figure 4) of the mass, while the right ventricular function improved. The patient was discharged on coumadin therapy. The findings from the echocardiographic study established the diagnosis of obstruction of the main pulmonary artery with possible subsequent pulmonary embolism due to thrombus formation. The visualisation of thrombus within the right cavities of the heart is not common, while