Caught in the middle: Thrombus-in-transit through patent foramen ovale

Thrombus-in-transit entrapped by patent foramen ovale (PFO) is a clinically well-recognized phenomenon that is extremely difficult to demonstrate by echocardiography due to its transient nature. We describe a case of thrombus-in-transit trapped within a PFO during paradoxical embolization with the help of echocardiographic images. A 70-year-old female with a known history of pulmonary hypertension presented to the emergency room with altered mental status, syncope and severe hypotension. She was intubated and mechanically ventilated for severe respiratory distress. Neuroimaging revealed an acute left occipital infarct. A transthoracic echocardiography, performed to evaluate for embolic source, demonstrated a mobile echo-dense mass attached to the atrial septum within the right atrium (Fig. 1). Transesophageal echocardiography (TEE) confirmed a thrombus-in-transit through the PFO (Fig. 2/Video 1). Further work up revealed acute deep vein thrombosis in right lower extremity. She was deemed to be poor surgical candidate and managed conservatively with systemic anticoagulation. Follow up echocardiogram did not show any thrombus in the atria suggesting paradoxical embolism (Fig. 3). She was terminally c o r e t v a s a 5 7 ( 2 0 1 5 ) e 5 9 – e 6 0