Right ventricular thrombus, a challenge in imaging diagnostics: a case series

Background Presence of right ventricular thrombus (RVT) is a rare but Life-threatening condition, thus immediate diagnosis and therapy are mandatory. Unfortunately, detection and distinction from intraventricular tumour masses or vegetations represent a complex task. Furthermore, consecutive therapy is principally led by clinical presentation without considering morphological features of the thrombus. Current literature suggests a multimodal non-invasive imaging approach. In this article, we discuss the role of cardiac magnetic resonance imaging (CMR) for the detection of RVT in patients with pulmonary embolism (PE). We consider the relatively expensive and not broadly available imaging procedure and weigh it up to its assumed high sensitivity, specificity, and importance for differential diagnosis and therapeutic decision-making. Case summary In this case series, we report three cases of RVT with concomitant PE, whereof two were missed during routine cardiac workup by transthoracic echocardiography and computer tomography. Cardiac magnetic resonance imaging led to detection and further characterization of the thrombi in both cases. Conclusions Cardiac magnetic resonance imaging reliably detects and characterizes RVT, even under unfavourable conditions for echocardiography such as arrhythmia, adiposity, or in posterior position of RVT. Obtained information could facilitate the choice of therapeutic approach (anticoagulation vs. systemic lysis vs. surgical thrombectomy). Future risk stratification scores will promote cost-effective use of CMR.