Knock knock, who's there?: intracardiac giant thrombi.

Abstract

A 52-year-old male presented to our emergency department with shortness of breath and chest discomfort. Bedside echocardiography showed right ventricular dilatation, which is associated with a slight elevation of estimated pulmonary systolic pressure. A computed tomography scan showed bilateral peripheral pulmonary embolisms. Conservative treatment with anticoagulant medications was initially chosen because the patient was in a hemodynamically stable condition. Transthoracic echocardiograms on the following day showed several mobile structures ‘dancing’ in the right atrium, which suggested thrombi (see Supplementary data online, Moving Image A). The patient underwent an urgent open-chest thrombectomy. A perioperative transoesophageal echocardiography revealed thrombi in the right atrium that were pushing the atrial septum as if saying ‘knock knock, who’s there?’ (Panels A and B, Supplementary data online, Moving Image A). A giant thrombus stuck in a patent foramen ovale (PFO) (Panel C, Supplementary data online, Moving Image A) was extracted, and PFO closure was performed. The patient was discharged home on postoperative Day 14 without any neurological deficit or respiratory problems. The phenomenon is well known as a paradoxical embolus; however, the transoesophageal echocardiographic images witnessing the very moment of it intruding towards the left atrium together with the actual surgery findings are rare and very impressive.