Large right atrial clot presenting as acute pulmonary thromboembolism in a case of rheumatic mitral stenosis after PTMC

Acute pulmonary embolism is a potentially fatal disease associated with a number of cardiac and non-cardiac predisposing factors. The association of rheumatic mitral valvular with right atrial thrombus in the absence of right ventricle dysfunction is extremely rare but is a possibility and a crucial differential diagnosis which needs to be kept in mind in a patient presenting with acute worsening of dyspnoea. Here we are presenting a case of a 37 year old female with severe rheumatic mitral stenosis in atrial fibrillation who presented to us with acute pulmonary thromboembolism with a large right atrial clot a month after she underwent a PTMC procedure. The patient had been on oral anticoagulation after the procedure and the INR was found to be therapeutic at the time of admission. The presence of a large right atrial clot was an unexpected finding in this case in the absence of right ventricular dysfunction and any other obvious pro-thrombotic predisposing factor except for atrial fibrillation. The occurrence of delayed right atrial thrombus may be related to instrumentation for septal puncture during PTMC for which the interventionists should be vigilant about in the immediate post-procedure period.