Catheter extraction of high risk right atrial clot, technical tips, and lessons learned. successes and failures

Floating right atrial (RA) thrombus in the presence of intracardiac shunting, patent foramen ovale (PFO), or atrial septal defect is a complex clinical challenge. Surgical thrombectomy, thrombolytic therapy, and long‐term anticoagulation are all available management options. However, surgical therapy and thrombolytic therapy both carry significant inherent risk and there is lack of data to support adequacy and efficacy of long‐term anticoagulation. We report for the first time a case of a large free floating RA thrombus in the presence of a large PFO in a patient where surgical intervention and thrombolytic therapy were both felt to be contraindicated. A combined AngioVac thrombectomy procedure and a PFO closure were performed simultaneously and successfully without the fragmentation of the clot or the protrusion and migration of the clot systemically through the large PFO. A second case without the associated presence of a PFO is also being reported where the procedure failed to extract the thrombus.