Abstract
Hepatocellular carcinoma (HCC) is a complication of end stage liver disease. Even rarer is right atrial tumor thrombus burden due to HCC. Common metastatic sites of HCC in descending order are lung, peritoneum, and bone. We present a patient with liver cirrhosis due to nonalcoholic fatty liver disease (NAFLD) admitted due to incidental finding of right atrial thrombus on echocardiography after missing HCC surveillance for four years. Patient received a computed tomography (CT) scan that showed an inconclusive liver lesion despite two liver biopsies, and patient was incidentally found to have clear cell HCC diagnosed after right hepatectomy. Right atrial thrombus was treated with surgical thrombectomy and pathology showed necrotic HCC thrombi in right atrium with bile pigment. Due to the possibility of tumor growth with extrahepatic manifestations, screening in compensated cirrhosis is essential.