Introduction: The incidence of pulmonary thromboembolism (PTE) associated with thrombus in the right heart cavity is estimated at 4% and is associated with a mortality of 27-45%, most fatal events happening in the first 24 hours. The concomitant presence of interatrial communication has an even lower incidence and, in addition, involves a higher risk of systemic embolization. Cardiac ultrasound is a simple gesture, which should be performed as soon as possible in any suspi-cion of PTE, being useful in risk stratification, but also in identifying intracavitary thrombosis, that influences the therapeutic attitude. The ESC guideline recommends systemic thrombolysis in high-risk PTE and sugges-ts that surgical thrombectomy should be taken into consideration in cases of contraindication for thrombolysis or when this has not been effective, but shows no indications for other clinical cases. We therefore present a dramatic and very rare case of high-risk PTE with extensive right and left intracavitary thrombosis and which has resulted in bilateral renal embolism.

Case presentation: A 48-year-old woman, with chest pain and severe dyspnea, was transferred, with the pre-sumptive diagnosis of inferior and right ventricle acute myocardial infarction with ST-segment elevation with cardiogenic shock, double antiplatelet therapy being initiated. She was hemodynamically unstable, with respiratory failure, minor metrorrhagia and moderate anemia. Echocardiography performed in our emergency department showed severe RV dysfunction and a hypermobile thrombus in the right atrium passing through an interatrial communication in the left atrium with extension through the mitral valve and aortic val-ve. Chest CT confirms bilateral PTE. We decided on thrombolysis and anticoagulation, considering the high-risk PTE, despite the moderate risk of bleeding. The clinical condition has clearly improved. Echocardiography did not reveal any remaining intracardiac thrombus. However, the patient developed severe ab-dominal pain at 1-hour post-thrombolysis, oligo-anuria, and decreased hemoglobin levels. Abdominal CT detects bilateral occlusion of the renal arteries. Thrombus aspiration was performed, with the resumption of renal flow. However, the patient developed multiple or-gan failure and died quickly within the first 24 hours.

Particularities of the case: T he particularities of the case consist in illustrating the therapeutic difficulties imposed by a very rare case, which combines high risk PTE with right intracardiac thrombus and extension through an interatrial communication in the left heart, in a hemodynamically unstable patient with signifi-cant hemorrhagic risk. The therapeutic decision was to balance systemic thrombolysis, which involved the risk of systemic embolization and hemorrhage (dou-ble antiplatelet, moderate-severe anemia and metrorrhagia). Moreover, at the time of the decision, surgi-cal thrombectomy was not available in the hospital. The patient presented a fatal complication of systemic thrombolysis, respectively embolization in both renal arteries. The European guideline recommends surgical thrombectomy only if thrombolysis is contraindicated or unsuccessful, but does not specify indications for situations similar to those illustrated in the case presented. Therefore, we highlight an area not covered by the indications in the guidelines.