CASE PRESENTATION: A 61 year old male presented to the emergency department with a three day history of orthopnea, shortness of breath, and lower extremity edema. His past medical history is significant for: RV failure secondary to arrythmogenic right ventricular cardiomyopathy (ARVC) status post implantable cardioverter defibrillator, heart failure with preserved systolic function, and persistent atrial fibrillation on apixaban. On presentation, he was tachypneic, hypoxic, and started on non-invasive positive pressure ventilation. Vital signs were: BP 120/86, HR 90, RR 35, O2 sat 93% on 60% FIO2. Physical exam revealed an irregularly irregular rhythm, bilateral inspiratory crackles, and 3+ pitting edema. Chest X-ray revealed a triple lead ICD (two RV leads) and perihilar interstitial and alveolar densities consistent with pulmonary edema. TTE was significant for severely reduced RV function and a hyperechoic immobile mass in the RV apex measuring 28mm x 21mm concerning for thrombus. The next day the patient underwent CT thorax for evaluation of acute respiratory failure. CT was consistent with severe pulmonary edema, but would also reveal a type IV LAD with significant pericoronary fat near the RV apex.