• accident and emergency medicine
• adult cardiology
• echocardiography
• thromboembolism
• adult intensive and critical care

A 46-year-old man, with acute-on-chronic hepatic failure and dilated cardiomyopathy, was admitted in the intermediate care unit after a sudden episode of dyspnoea without hypotension but with an elevated lactate of 3.9 mmol/L. He had an international normalised ratio of 3 and decreased factor V of 32.9%.

A bedside echocardiogram, while on sinus rhythm, revealed a mobile right atrial mass (figure 1A,B; see videos in supplementary material). Both ventricles were dilated with severely depressed function. No thrombi were present in a previous examination, 3 days before.