Abstract
Right ventricular thrombus (RVT) is a rare but potentially fatal entity, often representing a thrombus in transit with high risk for embolization and obstructive shock. Management is particularly complex in oncology patients, where anticoagulation and thrombolysis may be contraindicated. We present a 49-year-old woman with newly diagnosed, locally advanced urothelial carcinoma (T4N3M0), who developed a 3.0 × 2.2 cm mobile thrombus within the right ventricular outflow tract (RVOT), detected by transthoracic echocardiography and corroborated by contrast-enhanced chest CT. Her course was complicated by active vaginal bleeding, thrombocytopenia (platelets: 40-60 × 10⁹/L), and coagulopathy (international normalized ratio: 1.6), precluding anticoagulation or systemic thrombolysis. Catheter-directed thrombectomy with AngioVac (AngioDynamics Inc., Latham, NY) was attempted but was unsuccessful. Pathology confirmed a bland thrombus, excluding tumor invasion. Despite placement of an inferior vena cava (IVC) filter, she suffered obstructive shock with hypotension (systolic blood pressure: ~70 mmHg), hypoxemia (oxygen saturation: 70% on supplemental oxygen), and supraventricular tachycardia, requiring cardioversion, vasopressors, and intubation. Her condition further declined with extensive bilateral deep vein thromboses, methicillin-resistant Staphylococcus aureus (MRSA) bacteremia requiring intravenous antibiotics, progressive anemia, and metastatic progression despite two cycles of MVAC (methotrexate, vinblastine, doxorubicin, and cisplatin) chemotherapy. Following a multidisciplinary review, curative options were exhausted, and she transitioned to comfort care. This case illustrates the diagnostic challenges and therapeutic limitations of RVT in cancer patients with contraindications to standard therapies. Prognosis is poor when anticoagulation and thrombolysis are not feasible, and no consensus guidelines exist for this population. Early multidisciplinary coordination and integration of palliative care are essential to balance aggressive interventions with quality-of-life considerations.