Document Type

Conference Proceeding - Restricted Access

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Journal of the American College of Cardiology


Background: Thrombus-in-transit through a patent foramen ovale (PFO) is a rare, potentially fatal event. It has been documented in few case reports and intervention can be difficult and precarious. Case: A 69-year-old man, with CAD with bypass, stenting, and implantable cardioverter defibrillator (ICD), presented with multiple ICD discharges and chest pain. Device interrogation showed shocks after episodes of atrial fibrillation. He underwent a cardiac catheterization with subsequent left circumflex stenting. Transesophageal echocardiography showed the presence of a mobile left atrial thrombus (Figure 1A) that crosses a PFO (Figure 1B) and originates from the right atrial pacemaker lead (Figure 1C). A CT angiogram revealed bilateral PE with clot in the intrahepatic IVC and thrombus attached to the right ventricular ICD lead. The patient is awaiting surgery. Decision-making: This is a complex case of intra-cardiac thrombus and PE that likely originated as a deep vein thrombus. Much of the clot was caught by the ICD lead and became ensnared in the PFO. There is significant clot in the atria; this may have led to a reduced pulmonary clot burden. Definitive treatment involves open-heart surgery; however, the patient must remain on dual antiplatelet therapy due to recent coronary stenting. Clopidogrel was converted to cangrelor. Conclusion: Thrombi in transit across a PFO can be difficult to treat, especially in patients with concurrent coronary artery disease with stenting requiring antiplatelet therapy.




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