Warning regarding thrombosis-in-transit across the patent foramen ovale associated with pulmonary embolism: ultrasonographic imaging analysis.

Contrast-enhanced CT is useful for diagnosing Pulmonaly embolism (PE) but not for foramen ovale thrombi. Therefore, cardiac ultrasonographic observation of the atrial septum is important to avoid overlooking foramen ovale thrombi.

A 55‐year‐old man (body mass index, 58) was transported to our emergency room for dyspnea. Cardiac ultrasonography (Fig. 1A) was carried out, and a high‐intensity mass lying across the foramen ovale was displayed. The edge of the mass was going back and forth between the left ventricle and atrium (Video S1). There was no deep vein thrombosis on contrast‐enhanced computed tomography. The patient was diagnosed as having pulmonary embolism and thromboembolism‐in‐transit across a patent foramen ovale. A massive thrombus was found to be moving to the left atrium, which indicated a very critical state, and open thrombectomy was performed. Transesophageal echography during surgery also displayed a thrombus trapped in the foramen ovale (Fig. 1B), and a giant thrombus, 20 cm long, was removed (Fig. 1C).

Fig. 1

A, Transthoracic echocardiography of a 55‐year‐old man displaying a thrombus spanning the atrial septum. The thrombus moved to the left atrium side over time. B, Transesophageal echocardiogram during surgery also showed the thrombus trapped in the foramen ovale. The end of the thrombus was going back and forth between the left ventricle and atrium. C, The 20‐cm thrombus removed by surgery.

Patent foramen ovale has a high prevalence of 20–30% of all people.1 Patent foramen ovale combined with a pulmonary embolism could cause a thrombus to readily pass through and serious arterial embolism because of a right–left shunt caused by the increased pulmonary arterial pressure.2

Contrast‐enhanced computed tomography is useful for diagnosing pulmonary embolism but not for foramen ovale thrombi. Therefore, cardiac ultrasonographic observation of the atrial septum is important to avoid overlooking foramen ovale thrombi.

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Conflict of interest: N/A.

Video S1. The edge of the mass is going back and forth between the left ventricle and atrium.

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