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This case highlights the utility of echocardiography in identifying a rare thrombus in transit straddling a patent foramen ovale, which was successfully managed with surgical embolectomy.
A 54-year-old previously healthy woman presented with shortness of breath following a long car journey. The patient was found to have massive pulmonary embolism on computed tomography (CT) angiography (Fig. 1). Transthoracic echocardiography showed a dilated and poor-functioning right ventricle with a snake-like large mobile thrombus extending from the inferior vena cava (Video 1) to the right atrium and prolapsing to the right ventricle (Video 2) across the tricuspid orifice with each diastole (Video 3). The thrombus was entrapped in the patent foramen ovale (PFO) and extended to the left atrium, protruding into the left ventricle through the mitral valve (Video 4). There was no sign of peripheral emboli. The patient underwent urgent surgical embolectomy. Post-operative course was complicated with a large pericardial effusion that required drainage. The patient was well at 6 months follow-up. Figure 1 CT angiogram of the chest showing bilateral pulmonary embolism (circles). Ao, aorta; MPA, main pulmonary artery; RPA, right pulmonary artery; LPA, left pulmonary artery. Video 1 Transthoracic echocardiogram from subxiphoid view showing a large snake-like thrombus extending from the inferior vena cava (IVC) to the right atrium (RA). Download Video 1 via http://dx.doi.org/10.1530/ERP-14-0033-v1. Download Video 1 Video 2 Transthoracic parasternal long-axis echocardiogram showing the mobile thrombus in the right ventricle. Download Video 2 via http://dx.doi.org/10.1530/ERP-14-0033-v2. Download Video 2 Video 3 Transthoracic four-chamber echocardiogram showing a large mobile thrombus entrapped in the patent foramen ovale (PFO). Thrombus extends from atria to ventricles during diastole. Download Video 3 via http://dx.doi.org/10.1530/ERP-14-0033-v3. Download Video 3 Video 4 Transthoracic four-chamber echocardiogram showing a large mobile thrombus entrapped in the patent foramen ovale (PFO). Thrombus extends from atria to ventricles during diastole. Download Video 4 via http://dx.doi.org/10.1530/ERP-14-0033-v4. Download Video 4 Thrombus straddling the PFO rarely occurs as a consequence of thromboembolism, with the migration of thrombus to the left-sided chambers. Most reported cases have been treated with surgical embolectomy (1), yet there is no medical consensus about the best option for treatment with anticoagulant treatment remaining an acceptable alternative to surgery in patients at high risk for surgery (2).
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Salehi et al. (2014) studied this question.
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