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Thrombus-in-transit entrapped in a patent foramen ovale and related to underlying antiphospholipid syndrome.

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 ​and2).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. 
 
 
 
 
 
Fig. 2. 
 
Transthoracic echocardiogram (subcostal view) shows a large thrombus crossing a patent foramen ovale. The thrombus extends to the right ventricle during diastole.