Editorial Type:
Article Category: Research Article
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Online Publication Date: Jun 01, 2015

Thrombus-in-Transit Entrapped in a Patent Foramen Ovale and Related to Underlying Antiphospholipid Syndrome

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MD
Page Range: 296 – 297
DOI: 10.14503/THIJ-14-4286
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A 55-year-old man with a history of hypertension, diabetes mellitus, and recently diagnosed new-onset heart failure presented with dyspnea on exertion and pre-syncope. A transthoracic echocardiogram revealed a 4.5 × 1.2-cm biatrial thrombus that was traversing a patent foramen ovale (PFO) and abutting both atrioventricular valves (Figs. 1 and 2). The patient had no symptoms consistent with pulmonary or systemic embolization, so he did not undergo an evaluation for this. However, a Doppler-mode echocardiographic study of the lower extremities revealed acute venous thrombosis in the distal popliteal vein. Because of the substantial mobility of the thrombus and the risk of a thromboembolic event, the patient underwent emergency thrombectomy and closure of the PFO. Results of a hypercoagulability evaluation were positive for antiphospholipid antibody. The patient recovered uneventfully from the surgery but ultimately refused long-term anticoagulation therapy.

Fig. 1. Transthoracic echocardiogram (4-chamber view) shows a 4.5 × 1.2-cm mobile thrombus (arrow) crossing the intra-atrial septum through a patent foramen ovale. / Supplemental motion image is available for Figure 1.Fig. 1. Transthoracic echocardiogram (4-chamber view) shows a 4.5 × 1.2-cm mobile thrombus (arrow) crossing the intra-atrial septum through a patent foramen ovale. / Supplemental motion image is available for Figure 1.Fig. 1. Transthoracic echocardiogram (4-chamber view) shows a 4.5 × 1.2-cm mobile thrombus (arrow) crossing the intra-atrial septum through a patent foramen ovale. / Supplemental motion image is available for Figure 1.
Fig. 1. Transthoracic echocardiogram (4-chamber view) shows a 4.5 × 1.2-cm mobile thrombus (arrow) crossing the intra-atrial septum through a patent foramen ovale. Supplemental motion image is available for Figure 1.

Citation: Texas Heart Institute Journal 42, 3; 10.14503/THIJ-14-4286

Fig. 2. Transthoracic echocardiogram (subcostal view) shows a large thrombus crossing a patent foramen ovale. The thrombus extends to the right ventricle during diastole. / Supplemental motion image is available for Figure 2.Fig. 2. Transthoracic echocardiogram (subcostal view) shows a large thrombus crossing a patent foramen ovale. The thrombus extends to the right ventricle during diastole. / Supplemental motion image is available for Figure 2.Fig. 2. Transthoracic echocardiogram (subcostal view) shows a large thrombus crossing a patent foramen ovale. The thrombus extends to the right ventricle during diastole. / Supplemental motion image is available for Figure 2.
Fig. 2. Transthoracic echocardiogram (subcostal view) shows a large thrombus crossing a patent foramen ovale. The thrombus extends to the right ventricle during diastole. Supplemental motion image is available for Figure 2.

Citation: Texas Heart Institute Journal 42, 3; 10.14503/THIJ-14-4286

Comment

Thrombus-in-transit can present with various symptoms, including tachycardia, shortness of breath, and chest pain atypical of angina.1–5 It is often associated with clinical risk factors such as hypercoagulability disease, cancer, and estrogen use.1–3 Thrombus-in-transit is frequently associated with pulmonary embolism or paradoxical embolism.1 Treatment options include anticoagulation, administration of tissue plasminogen activator, and surgical removal,1 but the optimal treatment approach is unknown.5 In most reported cases, patients underwent surgical removal, as did our patient. To our knowledge, this is the first reported case of thrombus-in-transit related to underlying antiphospholipid syndrome.

References

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Copyright: © 2015 by the Texas Heart® Institute, Houston
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Fig. 1.
Fig. 1.

Transthoracic echocardiogram (4-chamber view) shows a 4.5 × 1.2-cm mobile thrombus (arrow) crossing the intra-atrial septum through a patent foramen ovale.

Supplemental motion image is available for Figure 1.

Fig. 2.
Fig. 2.

Transthoracic echocardiogram (subcostal view) shows a large thrombus crossing a patent foramen ovale. The thrombus extends to the right ventricle during diastole.

Supplemental motion image is available for Figure 2.

Contributor Notes

Section Editor: Raymond F. Stainback, MD, Department of Adult Cardiology, Texas Heart Institute, 6624 Fannin St., Suite 2480, Houston, TX 77030

From: Division of Cardiology, Department of Internal Medicine, Loyola University Chicago Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois 60153

Dr. Phan is now at the Division of Cardiology, San Francisco General Hospital, Department of Medicine, University of California, San Francisco.

Address for reprints: Taishi Hirai, MD, Division of Cardiology, Department of Internal Medicine, Loyola University Chicago Stritch School of Medicine, Loyola University Medical Center, 2160 S. First Ave., Maywood, IL 60153, E-mail: taishi.hirai@gmail.com