Abstract
Pulmonary embolism (PE) is classified into massive, submassive, and low-risk categories, with severity often assessed using tools such as the Pulmonary Embolism Severity Index (PESI) and simplified PESI (sPESI) to determine inpatient versus outpatient management. This report discusses an 84-year-old male with a history of prostate cancer (not on chemotherapy), hypertension, type 2 diabetes mellitus, and hyperlipidemia, who developed bilateral PE and a right heart thrombus in transit after a syncopal episode during hospitalization for a viral illness. A right heart thrombus in transit is a mobile clot within the right heart chambers or vena cava, posing a high risk for further embolization. These thrombi are often visualized on echocardiography and are considered a medical emergency. Although the patient remained hemodynamically stable, evidence of right ventricular dysfunction confirmed by laboratory markers (e.g., elevated troponin and BNP levels) and imaging studies was consistent with the diagnosis of submassive PE. Management of right heart thrombi in transit remains controversial due to the lack of randomized controlled trials. Treatment options include systemic anticoagulation, systemic or catheter-directed thrombolysis, catheter-based embolectomy, and surgical thrombectomy. In elderly patients with multiple comorbidities, selecting the optimal approach requires multidisciplinary input. This case highlights the critical need for multidisciplinary evaluation and the complexity of managing right heart thrombi and the importance of individualized treatment strategies in high-risk patients.