Location
Philadelphia, PA
Start Date
30-4-2025 1:00 PM
End Date
30-4-2025 4:00 PM
Description
Background: Clot-in-transit is a rare medical emergency presenting imminent risk of infarction to distal tissue. In patients with a patent foramen ovale—prevalent in about 25% of the population,1 paradoxical embolism is a possibility. Managing these patients is challenging, given the disconnect between apparent clinical stability and true severity of disease, as demonstrated in our case.
Case Presentation: A 46-year-old male presented to the emergency department with a 6-week history of exertional dyspnea and pleuritic chest pain. Transthoracic echocardiography revealed a clot-intransit trapped across an atrial septal defect with mobile left- (1.3 x 1.2 cm) and right-sided (3.9 x 0.7 cm) components, and decreased systolic function of the right ventricle with abnormal septal bowing and a right ventricular systolic pressure of >60 mmHg. Transesophageal echocardiography revisualized the thrombus in the atrial septum, measuring 2.3 x 0.6 cm in the left atrium. Via cardiopulmonary bypass, the clot-in-transit was successfully removed through the right atrium and an opened fossa ovalis.
Discussion: Discovery of a thrombus in a septal defect, alongside echocardiographic findings suggestive of pulmonary hypertension, escalated the patient to high-risk despite stable hemodynamics, as altered intracardiac pressure dynamics were likely contributing to ongoing propagation of the thrombus through the patent foramen ovale. No standardized guidelines for clot-in-transit management currently exist, with treatment options mirroring those of intermediate/high-risk pulmonary embolism (systemic thrombolysis, catheter-based interventions, surgical embolectomy). Systemic thrombolysis remains first-line at present, with invasive interventions reserved for when thrombolysis is contraindicated/unsuccessful, though recommendations are evolving with recent advancements in catheter-based interventions showing promise. In our patient, substantial clot burden in both atria raised concerns about clot fragmentation and subsequent embolization into pulmonary/systemic circulations with systemic thrombolysis and a catheter-based approach. Surgical embolectomy was felt to be the ideal approach as it allowed safer clot-in-transit removal with septal defect closure. This case highlights how risk stratification and management for acute pulmonary embolism can rapidly change following clot-in-transit identification. Guidelines should include clot-in-transit as a high-risk criterion to improve treatment planning.
Embargo Period
5-29-2025
Included in
Caught in Transit: Thrombus Trapped in a Patent Foramen Ovale
Philadelphia, PA
Background: Clot-in-transit is a rare medical emergency presenting imminent risk of infarction to distal tissue. In patients with a patent foramen ovale—prevalent in about 25% of the population,1 paradoxical embolism is a possibility. Managing these patients is challenging, given the disconnect between apparent clinical stability and true severity of disease, as demonstrated in our case.
Case Presentation: A 46-year-old male presented to the emergency department with a 6-week history of exertional dyspnea and pleuritic chest pain. Transthoracic echocardiography revealed a clot-intransit trapped across an atrial septal defect with mobile left- (1.3 x 1.2 cm) and right-sided (3.9 x 0.7 cm) components, and decreased systolic function of the right ventricle with abnormal septal bowing and a right ventricular systolic pressure of >60 mmHg. Transesophageal echocardiography revisualized the thrombus in the atrial septum, measuring 2.3 x 0.6 cm in the left atrium. Via cardiopulmonary bypass, the clot-in-transit was successfully removed through the right atrium and an opened fossa ovalis.
Discussion: Discovery of a thrombus in a septal defect, alongside echocardiographic findings suggestive of pulmonary hypertension, escalated the patient to high-risk despite stable hemodynamics, as altered intracardiac pressure dynamics were likely contributing to ongoing propagation of the thrombus through the patent foramen ovale. No standardized guidelines for clot-in-transit management currently exist, with treatment options mirroring those of intermediate/high-risk pulmonary embolism (systemic thrombolysis, catheter-based interventions, surgical embolectomy). Systemic thrombolysis remains first-line at present, with invasive interventions reserved for when thrombolysis is contraindicated/unsuccessful, though recommendations are evolving with recent advancements in catheter-based interventions showing promise. In our patient, substantial clot burden in both atria raised concerns about clot fragmentation and subsequent embolization into pulmonary/systemic circulations with systemic thrombolysis and a catheter-based approach. Surgical embolectomy was felt to be the ideal approach as it allowed safer clot-in-transit removal with septal defect closure. This case highlights how risk stratification and management for acute pulmonary embolism can rapidly change following clot-in-transit identification. Guidelines should include clot-in-transit as a high-risk criterion to improve treatment planning.