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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Cardiac masses and intracardiac thrombus

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Escalate

A mobile mass causing valve/inflow obstruction, systemic embolism, sepsis with valve destruction, right-heart thrombus in transit or threatened coronary/cerebral embolisation requires same-day multidisciplinary cardiology care; haemodynamic collapse follows the relevant shock, PE or endocarditis surgical pathway.

Synopsis

Classify an intracardiac mass as thrombus, tumour, vegetation or mimic and act on embolic, obstructive and infective risk before tissue certainty.

  • First exclude artefact and normal variants, then classify by chamber, attachment, mobility, haemodynamic effect, vascularity and clinical setting.
  • Thrombus favours stasis sites: LAA in AF/mitral stenosis, LV apex after MI or severe dysfunction, and right atrium around lines or with venous thromboembolism.
  • Vegetation is an infected endocardial mass—usually mobile on a valve or device—with fever, bacteraemia, valve destruction or embolic/immunological features.
  • Tumour is less common than thrombus; atrial myxoma often arises by a stalk from the interatrial septum, while metastases are more common than primary malignant cardiac tumours.
  • TTE is the entry test; TOE is superior for valves, prostheses, device leads, LAA and small posterior lesions.
  • CMR characterises tissue and perfusion; thrombus usually lacks perfusion/enhancement, whereas tumour often enhances, although organised thrombus can be complex.
  • Never anticoagulate an unidentified mass reflexively: vegetation, vascular tumour, recent haemorrhagic embolus and dissection carry different hazards.
  • A mass that shrinks on effective anticoagulation supports thrombus, but interval response must not delay surgery for obstruction, embolisation or suspected malignancy.

Key red flags

Obstruction or embolism

Positional syncope, acute valve obstruction, stroke/limb ischaemia, coronary embolism or a highly mobile left-sided mass requires urgent surgical/embolism assessment.

Malignant features

Broad-based infiltration, rapid growth, multiple lesions, pericardial invasion/effusion, known cancer or constitutional symptoms requires urgent cardio-oncology and tissue strategy.

Investigation priorities

01
Comprehensive TTE with ultrasound contrast when neededFirst step

Confirm the mass, location, attachment, mobility, haemodynamic effect and cavity opacification.

Management branches

ClassifyNew intracardiac mass

Mass or filling defect on echo, CT or CMR.

  1. Confirm it in a second plane/modality and compare prior imaging; map chamber, attachment, mobility, obstruction and embolic risk while excluding artefact/normal variants.
  2. Ask immediately about AF/MI/LV dysfunction, venous catheters/DVT, fever/cultures/procedures, cancer and constitutional or embolic symptoms.
  3. Choose TOE for valve/LAA/device targets, CMR for tissue and CT for calcification/coronary or surgical anatomy; do not order every modality without a decision question.
  4. If haemodynamic, embolic or septic instability exists, treat the leading emergency in parallel rather than awaiting definitive histology.

Key medicines

WarfarinTypical maintenance 3-9 mg orally once daily, individually titrated; when a VKA is selected for non-mechanical intracardiac thrombus, a common specialist target is INR 2.0-3.0.Never use a fixed dose without INR monitoring. Review bleeding, pregnancy, liver disease, diet and interacting medicines; the target differs with valve type/site and a new interacting medicine warrants early INR recheck.
ApixabanFor licensed NVAF stroke prevention: 5 mg orally twice daily. Use 2.5 mg twice daily when at least two apply—age at least 80 years, weight 60 kg or less, serum creatinine at least 133 micromol/L—or when creatinine clearance is 15-29 mL/min.Not for mechanical valves or moderate-to-severe rheumatic mitral stenosis. Check Cockcroft-Gault creatinine clearance, hepatic function, bleeding and CYP3A4/P-gp interactions; do not underdose from age alone, and avoid use below creatinine clearance 15 mL/min because there is no clinical experience.
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Sources and review status6 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • ESC/EACVI recommended reading: Cardiac masses and sources of emboliSociety imaging framework for masses, thrombus and embolic sources.
  • 2023 ESC Guidelines for the management of endocarditisVegetation, cultures, TOE, multimodality imaging and Endocarditis Team pathway.
  • 2019 ESC Guidelines on acute pulmonary embolismRisk-adjusted emergency treatment for right-heart thrombus with PE.
  • NICE NG196: Atrial fibrillationUK AF anticoagulation and LAA-occlusion boundaries.
  • Warfarin 0.5 mg tablets SmPCUsual maintenance dosing and INR-directed treatment.
  • Eliquis 5 mg SmPCLicensed NVAF dose, reduction criteria and cautions; established intracardiac-thrombus treatment is outside the listed indication.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom