Thrombus in transit through a patent foramen ovale: catch it if you can—a case report

Abstract

Background Patent foramen ovale (PFO) is one of the most common congenital heart defects, but the finding of a thrombus in transit (TIT) through a PFO is extremely rare. It’s a therapeutic challenge, and systemic anticoagulation, cardiac surgery or fibrinolysis should be considered. Case Summary A 43-year-old female was admitted with intermediate-high risk pulmonary embolism. Transthoracic echocardiogram revealed a large right atrial mobile mass that crossed the interatrial septum through a PFO, compatible with TIT, and the patient was started on unfractionated heparin. The diagnosis was confirmed by transesophageal echocardiogram (TEE). However, during TEE probe removal, the patient developed dyspnoea, sudoresis and peripheral desaturation, and new image acquisition revealed sudden mass disappearance. Due to the possibility of paradoxical embolization associated with Valsalva maneuver, fibrinolysis with alteplase was promptly started. The patient had no signs of embolic or hemorrhagic complications and remained clinically stable. She was discharged on warfarin and then underwent percutaneous transcatheter closure of PFO. Conclusion The treatment strategy of a TIT through a PFO is controversial, but surgery might be the most appropriate treatment for hemodynamically stable patients, while thrombolysis should be used in cases of hemodynamic instability. TEE is generally a safe procedure but pressure changes associated with Valsalva maneuver may induce embolization of a TIT and attention should be given to patient sedation and tolerance. After complete embolization of a TIT, emergent thrombolysis may be the only treatment option, in order to prevent disastrous consequences related to paradoxical embolism.

Acute Coronary Syndrome Followed by Pulmonary Thromboembolism and Identification of a Large Fixed Thrombus between Atria in a Patient with Severe COVID-19: A Case Report

“…2 If that occurs, the brain is the most frequently affected organ, followed by the coronary arteries. 1 It is not possible to state whether the identified interatrial thrombus was formed from the progression of a thrombus formed at the site or whether it was secondary to the expansion of an embolus from the lower limb or pelvis to the pulmonary artery, eventually "captured" by the PFO.…”

“…Treatment strategy of thrombus in transit is challenging and controversial, 1,2 but three possible approaches include anticoagulation, fibrinolysis or cardiac surgery, which have particular benefits and risks. 1,2 It is worth emphasizing that anticoagulation alone is primarily used in patients with comorbidities or patients who refuse invasive therapy. 1 Fibrinolysis should be considered in hemodynamically unstable patients with high surgical risk.…”

“…1,2 It is worth emphasizing that anticoagulation alone is primarily used in patients with comorbidities or patients who refuse invasive therapy. 1 Fibrinolysis should be considered in hemodynamically unstable patients with high surgical risk. 1 In view of the stability of the patient, this therapeutic option was not considered.…”

“…1 Fibrinolysis should be considered in hemodynamically unstable patients with high surgical risk. 1 In view of the stability of the patient, this therapeutic option was not considered. Furthermore, this approach may cause thrombus fragmentation with subsequent pulmonary and/or systemic embolization.…”

“…Patent foramen ovale (PFO) is a relatively frequent congenital heart defect; however, the identification of large thrombi between the atria through a PFO is a rare condition. 1 When visualized, they represent a major clinical challenge and require emergency treatment. 2 The severity of this condition becomes even more accentuated when associated with other thrombotic events, such as pulmonary embolism.…”