Transit Thrombus in a Patent Foramen Ovale — Time Is Running Out: a Case Report

We report a case of a large thrombus entrapped in a patent foramen ovale after bariatric surgery and pulmonary embolism. The 60-year-old female patient was admitted to hospital as an emergency after syncope. She suffered from metabolic syndrome with obesity (height: 180 cm, weight: 170 kg, BMI: 49.4 kg/m2) and an insulin-dependent diabetes mellitus type 2. She had had bariatric surgery (implantation of a gastric balloon) 4 weeks prior to hospitalization. A transthoracic echocardiography was performed which indicated a large entrapped thrombus in the patent foramen ovale with extensions of approximately 10 cm in both the right and the left heart. Surgical embolectomy was performed to remove the circa 20-cm-long thrombus.At the time of surgery, only 2 cm of the transit thrombus remained in the right atrium. Thus, during the time between diagnosis and emergency surgery, the thrombus had gradually migrated 8 cm. Pulmonary embolectomy and closure of the patent foramen ovale were performed during the same procedure. The patient recovered completely without any complications and was discharged 11 postoperatively. This case demonstrates the importance of urgent medical decision-making with transit thrombi — time is running out.