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Images in cardiology

Thrombus in transit through a patent foramen ovale

An obese 57-year-old woman presented to the emergency department with shortness of breath and palpitation that had been present for 1 day. On physical examination, the patient was noted to have rapid atrial brillation with a heart rate of about 178 bpm; her blood pressure was 120/60 mm Hg. Transthoracic echocardiography revealed a mobile echogenic mass in the atria. Doppler ultrasound showed deep venous thromboses in the lower extremities bilaterally. Transoesophageal echocardiography, gure 1, showed a large snake-like thrombus in transit from the right atrium into the left atrium through a patent foramen ovale (PFO). The patient underwent a mini sternotomy, thrombus extraction and PFO closure, and subsequent inferior vena cava

Figure 2

Thrombus after successful extraction.

lter placement was done the following day. Figure 2 shows a thrombus (1331.230.5 cm) with a band of constriction at the level where it traversed the defect. Thrombus in transit is a rare but clinically well recognised entity with a high overall mortality rate encountered in patients with deep venous thrombosis and PFO. Transthoracic echocardiography, or in some cases transoesophageal echocardiography, is the key investigation in such cases.1 Management of paradoxical embolus in transit includes initial systemic anticoagulation, with subsequent thrombectomy and surgical or percutaneous closure of PFO;2 thrombolysis may also be an alternative.

Murad Abdelsalam,1 Mubashir Mumtaz,2 Ira Sackman3

Department of Internal Medicine, Pinnacle Health Hospitals, Harrisburg, Pennsylvania, USA; 2Department of Cardiothoracic Surgery, Pinnacle Health Cardiovascular Institute, Harrisburg, Pennsylvania, USA; 3Department of Cardiology, PinnacleHealth Cardiovascular Institute, Harrisburg, Pennsylvania, USA Correspondence to Dr Murad Abdelsalam, Department of Internal Medicine, Pinnacle Health Hospitals, 111 S Front Street, Harrisburg, PA 17101, USA; murad.abdelsalam@gmail.com
< An additional video is published online only. To view this le please visit the journal
1

online (http://heart.bmj.com/content/98/15.toc). Contributors MA and MM wrote the initial manuscript. IS edited the paper, including image editing and paper design. All authors read and approved the nal manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed. Received 11 January 2012 Accepted 22 March 2012 Published Online First 9 May 2012

Figure 1 Transoesophegeal echocardiogram images show a large snake-like thrombus (A) trapped in a patent foramen ovale and extending into the right and left atria during systole, (B) prolapsing across the mitral and tricuspid valves into the left and right ventricles, respectively, during diastole. IAS, interatrial septum; LA, left atrium; LV, left ventricle; PFO, patent foramen ovale; RA, right atrium; RV, right ventricle; T, thrombus. Video 1, showed a large snake-like thrombus in transit from the right atrium into the left atrium through a patent foramen ovale (PFO).

Heart 2012;98:1184. doi:10.1136/heartjnl-2012-301659

REFERENCES
1. ra J, Delomez M, et al. Free-oating thrombi in the right heart Chartier L, Be diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation 1999;99:2779e83. Meacham RR, Stacey Headley A, Bronze MS, et al. Impending paradoxical embolism. Arch Intern Med 1998;158:438e48.

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Heart August 2012 Vol 98 No 15

Downloaded from pdf.highwire.org on March 21, 2013 - Published by group.bmj.com

Thrombus in transit through a patent foramen ovale

Murad Abdelsalam, Mubashir Mumtaz and Ira Sackman Heart 2012 98: 1184 originally published online May 9, 2012

doi: 10.1136/heartjnl-2012-301659

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