Dilated cardiomyopathy (DCM) is a kind of malignant cardiac disorder, which affects 5 in 100,000 adults and 0.57 in 100,000 children [1, 2]. It represents a poor long-term prognosis with the mortality rate is 70% to 80% at eight years for most patients who undergo heart failure [3]. Right heart thrombus presents higher mortality [4] with a risk of pulmonary embolization [5], which has been found in patients with DCM rarely. Echocardiography plays a pivotal role in the evaluation of DCM and intracardiac masses. To the best of our knowledge, this is the first case report using combination of two-dimensional echocardiography and real-time three dimensional echocardiography in the assessment of right atrial thrombus happened in DCM.

DCM is a multifactorial myocardial disease characterized by enlarged left or whole heart chambers and decreased heart function [6]. Symptoms of progressive heart failure are common in patients with dilated cardiomyopathy and endstage disease may predispose to arrhythmia associated with a high risk of thrombus formation which may lead to thromboembolic events [7]. Right heart thrombus happens about 4-18% cases with acute pulmonary embolism [8, 9], while rare found in patients with DCM. They may develop within right heart because of atrial fibrillation, hypercoagulable state caused by disease or origin from peripheral venous clots due to bedridden condition that temporarily embolized to the right heart. This type of thrombus presents higher mortality [4] with a risk of potential fragmentation and causing massive pulmonary embolization [5].

Echocardiography is the most important non-invasive comprehensive method in clinical diagnosis of DCM as well as evaluating intracardiac masses or thrombi. In our report, the patient had a right atrial mass with the severity of both ventricle dysfunctions. Although conventional 2DTTE can help to estimate cardiac structure, function and assess the hemodynamic effects, the RT-3DTTE adds valuable benefits as follows: (1) the RT-3DTTE can provide complete information of intracardiac masses[10] including size, shape, consistency, mobility and location that in relation to cardiac anatomical structures.(2) It allows us to differentiate the thrombus from other masses (e.g. cardiac tumors, vegetations) by revealing lobula, stalk, hyperechogenicity or hypoerechogenicity and spatial relationship with adjacent structures, which may help in demonstrating prognostic indications or the response to treatment.(3) In addition, RV dysfunction plays an important role in adverse outcome [11], RT-3DTTE provides a practical approach for quantified the RV function without relying on the geometric assumptions. (4) Patients with DCM usually have distorted LV shape. RT-3DTTE can quantify the LV function without long time breath holding and fully cooperative, also the result is more accurate even like as MRI technology [12]. In our presentation, the combination of 2DTTE and RT-3DTTE may facilitate the diagnosis in evaluating heart function and characterize the nature of thrombus better.

Written informed consent was obtained from the relative of the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.