Thrombus-in-transit through a patent foramen ovale

Abstract

Even though almost 30% of the general population presents a persistent foramen ovale (PFO) the paradoxical embolism is a rare finding (2% of arterial emboli) and the thrombus is rarely caught passing through the PFO. Diagnostic imaging remains the cornerstone for accurate diagnosis of a thrombus-in-transit, especially using transesophageal echocardiography (TEE) with a high specificity. There is a lack of evidence-based recommendations for the management. We report a 38-year-old female with an intermediate-low risk pulmonary embolism (PE). An entrapped thrombus across a PFO was revealed by TEE. Subsequent imaging has shown a splenic infarction thus confirming the diagnostic of paradoxical embolism. The main factor that led to right to left shunt through PFO was the irritating cough provoking a Valsalva maneuver. She underwent early surgical thrombectomy with PFO closure. Thrombus-in-transit remains a rare entity and an effective option of management is early surgical embolectomy. Further studies need to be done in order to establish the best management strategies.