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Mature mediastinal teratomas are infrequent, slow growing, and often asymptomatic. Traditionally, they present in the fourth decade or earlier and are found in the anterior mediastinum. These teratomas are often found incidentally on imaging, and surgical resection can be a challenge due to the size and location of the tumor; however, complete surgical excision is usually curative. Our case represents an infrequent benign giant (25 cm × 18 cm × 12 cm) mature intrathoracic mediastinal teratoma with uncommon clinical presentation of congestive heart failure and cardiac cachexia. The rare location of the tumor in the mid posterior mediastinum, very large teratoma, clinical presentation with right ventricular failure and cardiac cachexia, preoperative diagnostic dilemma, perioperative surgical challenge, and management marks this case unique.