Echocardiographic demonstration of a thrombus straddling the patent foramen ovale and pulmonary embolism

A 74-year-old woman presented with a 3-day history of increasing dyspnoea. She had undergone left hip arthroplasty following a car accident 5 weeks previously, resulting in prolonged bed rest. The patient was tachypnoeic, and blood pressure was 140/60 mmHg. Besides sinus tachycardia, the electrocardiogram revealed an S1Q3 pattern. NT-proBNP (4849 pg/ml) and D-dimers (3964 ng/ml) were increased. Transthoracic echocardiography (Panel A; RA: right atrium; LA: left atrium, see Supplementary dataSupplementary data online, Video S1) demonstrated a thrombus (*) straddling a patent foramen ovale (PFO), confirmed by transoesophageal echocardiography (TEE) (Panels B and C, see Supplementary data online, Videos S2Supplementary data online, Videos S2 and S3S3) which, in addition, detected another thrombus (**) in the right pulmonary artery (PA) (Panel D, see Supplementary dataSupplementary data online, Video S4). Computed tomography pulmonary angiogram showed multiple bilateral pulmonary emboli (Panel E). Emergent surgical thrombectomy and pulmonary embolectomy were performed (Panel F), followed by gradual clinical improvement under unfractionated heparin. Heparin-induced thrombocytopenia complicated by left popliteal artery thrombosis was diagnosed on the tenth postoperative day. Danaparoid sodium was initiated after thrombectomy.

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