Abstract
Introduction: Patent foramen ovale (PFO), seen in about 20-25% of the population, is linked with paradoxical embolism. However, a paradoxical thrombus seen in transit through a PFO is an extremely rare finding. Case: An 80-year-old-female with a history of stroke, atrial fibrillation (AF), and diabetes presented with a complaint of dizziness. She had a history of non-compliance with her anticoagulation for AF. EKG showed AF with rapid ventricular rate. An echocardiogram showed a large mobile thrombus in both atria representing a paradoxical embolus in transit caught in PFO (Figure A). Right ventricular systolic function was noted to be severely reduced. A transesophageal echocardiogram confirmed a paradoxical embolus in transit with a large amount of mobile thrombus in the left atrium (Figure B, C). Large saddle acute pulmonary embolus, extending bilaterally into main, lobar, and segmental pulmonary arteries, was seen on the CT chest (Figure D). Lower extremity ultrasound revealed right popliteal vein thrombosis extending to the peroneal vein. Due to a high risk of paradoxical systemic embolism patient underwent emergent surgical thrombectomy along with the closure of PFO. Conclusion: Paradoxical thrombus in transit through PFO carries a high risk of systemic embolism. Therapeutic options for patients include cardiac surgery with thrombectomy, thrombolysis, or systemic anticoagulation, with no clear consensus regarding the best treatment option.
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