Thrombus in Transit Through a Patent Foramen Ovale: A Clinical Conundrum.

BACKGROUND: Thrombus in transit through a patent foramen ovale (PFO) is a rare clinical entity that can be associated with concurrent pulmonary embolization and lead to cryptogenic stroke. CASE SUMMARY: A 56-year-old patient presenting with shortness of breath and chest pain was diagnosed with large bilateral pulmonary emboli. Computed tomography demonstrated thrombus in the right atrium. Transthoracic echocardiogram demonstrated a large burden of thrombus in transit trapped in a PFO. After multidisciplinary discussion, emergency surgical thrombectomy and PFO closure were carried out successfully. DISCUSSION: There are no current guidelines for management of a thrombus of this nature, but potential options include anticoagulation, thrombolysis, and mechanical or surgical thrombectomy. Previous case reviews have found that surgical embolectomy in low-moderate risk surgical patients resulted in fewer embolic events and a lower mortality rate. Compelling imaging of this phenomenon is presented. TAKE-HOME MESSAGES: Management decisions by a multidisciplinary team need to be on an individual case-to-case basis considering individual bleeding risk, surgical risk, and available expertise. Surgical thrombectomy with PFO closure has shown in a review of previous case studies to have an overall lower associated mortality and embolic risk.