Inter-atrial saddle thrombus: Crossing the PFO
Michaels AT, Mawri S, Gibbs J, Patel R, Hudson M. Inter-atrial saddle thrombus: Crossing the PFO. J Am Coll Cardiol. 2018;71(11)
J Am Coll Cardiol
Background: Venous thromboembolic events with clot across a patent foramen ovale (PFO) are rare and present unique challenges to acute management Case: A 64-year old healthy, active male presented with 4-days of exertional dyspnea frst noted while chopping wood. His symptoms progressed so that simple positional changes resulted in pre-syncopal symptoms forcing him to seek medical care. Initial evaluation revealed a normal exam apart from a loud P2. The electrocardiogram revealed a S1Q3T3 pattern along with a right bundle branch block. Labs showed an NT-proBNP >14,000ng/dL and mild troponin elevation. CT pulmonary angiogram confrmed a large saddle pulmonary embolus (PE) extending from the right ventricle to thepulmonary artery (PA) trunk and both main PAs with contrast refux in the hepatic veins. Transesophageal echo showed an additional serpiginous clot within the right atria across a PFO to the left atria Decision-making: Heparin therapy was started and our institutional PE response team were activated for evaluation of thrombolytics. Catheter directed therapy was not offered due to the clot burden nor were systemic lytics given due to the large PFO and risk of paradoxical stroke with hemorrhagic conversion. A surgical consult was obtained and the patient underwent successful thrombectomy and PFO closure Conclusion: This case demonstrates a successful multidisciplinary approach of a patient at high risk for paradoxical embolism with medical management while optimizing for surgical intervention.