Acute Pulmonary Embolism With a Left Atrial Thrombus Passing Through a Patent Foramen Ovale

A 74-year-old woman was transferred to hospital due to difficulty moving. Transthoracic echocardiography (TTE) revealed a right atrial (RA) thrombus, which computed tomography (CT) confirmed as well as revealing pulmonary artery (PA) embolism with a left atrial (LA) thrombus (Figure A–C). There was neither paradoxical arterial thrombus nor cerebral infarction. Blood tests revealed no thrombotic predisposition, but she had been less mobile after falling a few days prior.

Figure.

(A–C) Computed tomography images of the right and left atrial thrombi (red arrowheads) connected through the patent foramen ovale (PFO) (white arrow) (A). Emboli in both the right and left pulmonary arteries (PA) (red arrows) (B,C). Intraoperative TEE reveals the PFO (white arrow) (D), and the connected LA and RA thrombi (red arrows) through the PFO (white arrow) (E). Intraoperative findings. Thrombus trapped in the PFO (black arrow) (F). Gross images of thrombi from the RA, LA, left PA, and right PA (G).

We performed emergency surgery. Transesophageal echocardiography (TEE) showed that the LA thrombus had passed through a patent foramen ovale (PFO) and was connected to the RA thrombus (Figure D,E). We cross-clamped the ascending aorta and incised the RA, where a large thrombus was trapped in the PFO (Figure F). We carefully extracted the RA thrombus and successfully removed the LA thrombus through the PFO (Figure G), which was sutured closed before removing the thrombus in the PA.

A PFO can cause a paradoxical arterial thrombus.¹ Acute pulmonary embolism (PE) with a PFO requires emergency surgical treatment.

Disclosure

None.

IRB Information

Tokyo Saiseikai Central Hospital IRB granted an exemption from requiring ethics approval.

Ethical Statement

All procedures were in accordance with the “Declaration of Helsinki” and the Ethical Guidelines for Medical and Health Research Involving Human Subjects.

Reference

• 1.   Sakuma M, Nakamura M, Yamada N, Ota S, Shirato K, Nakano T, et al. Venous thromboembolism: Deep vein thrombosis with pulmonary embolism, deep vein thrombosis alone, and pulmonary embolism alone. Circ J 2009; 73: 305–309.