Crossing atrial thrombus in a patient with recurrent pulmonary embolism

OBJECTIVESTo report the detection of a thrombus entrapped in a patent foramen ovale by echocardiography in a patient with recurrent pulmonary embolism. DESIGNCase report. SETTINGIntensive care unit of a university hospital. PATIENTA 62-yr-old man with initial deep venous thrombosis and recurrent minor pulmonary embolism followed by a severe embolic event with transitory hemiparesis 10 days after prostatectomy. INTERVENTIONSystemic anticoagulation, surgical removal of a crossing atrial thrombus, closure of a patent foramen ovale, and venous thrombectomy. MEASUREMENTS AND MAIN RESULTSTransesophageal echocardiography revealed a large thrombus entrapped in a patent foramen ovale with portions in all four heart chambers. Intraoperatively, a 19-cm-long thrombus, shaped like the pelvic veins, was found. The patient was successfully weaned from cardiopulmonary bypass, requiring temporary positive inotropic support because of right ventricular dysfunction. Within 24 hrs of the operation, the patient was discharged to the intermediate care unit. CONCLUSIONSRecurrent pulmonary embolism can potentially result in paradoxic embolism in patients with a patent foramen ovale. In such patients, it may be crucial to monitor right ventricular function and exclude right-to-left shunts by transesophageal echocardiography, regardless of clinical symptoms. The patent foramen ovale should be closed. This case emphasizes an important indication for transesophageal echocardiography in critically ill patients.