Large embolic clot in transit straddling across patent foramen
ovale- Thrombotic railroading from LV outflow to right ventricle
Patient is a fourty five year old lady with history of seizure disorder
and diabetes. Patient was being being followed up with neurologist in
view of recurrent absent seizures, with memory loss and was on multiple
antiepileptic drugs since years. Since last one year, patient was bed
ridden and developed bilateral pedal swelling over last two months. She
had sudden onset dyspnoea at rest with no complain of angina,
palpitations, syncope or orthopnoea. Patient was in hypotension with BP
of 80/50 mm Hg with tachycardia and low volume pulse. Respiratory rate
was high, upto thirty five per minute and thoracoabdominal pattern.
Bilateral pedal edema was present, and jugular venous pressure was
raised. There was no cardiomegaly, heart sounds were normal with loud P2
and RVS3. Bilateral chest was clear with no features of pulmonary edema.
Electrocardiogram showed sinus tachycardia with T inversion in V1 to V3
leads and S1Q3T3 pattern. Lower limb doppler showed left lower limb deep
vein thrombosis involving illiofemoral vein. CT pulmonary angiogram was
done from referring hospital which showed bilateral acute thrombus in
right and left proximal pulmonary artery suggestive of acute pulmonary
embolism. Patient’s echocardiogram revealed positive McConnel sign and a
large thrombus across right atrium and right ventricle attached to the
interatrial septum. Clot was extending from left side of interatrial
septum to mitral valve and extending across aortic valve.[Fig 1-3]
Findings were suggestive of a large paradoxical clot in transit. Patient
was started on oxygen support and inotropes. Thrombolysis was planned
with half dose alteplase (50 mg) as slow infusion over 6 hours. Post
thrombolysis echocardiogram showed complete resolution of LV clot with
improved right ventricular function and decrease in RV systolic
pressures. Though patent foramen ovale (PFO) was not demonstrated on
contrast echocardiogram. Repeat CT pulmonary angiogram post thrombolysis
revealed no thrombus in bilateral proximal pulmonary arteries and some
residual clot was present in distal subsegmental branches. Patient
improved hemodynamically and was continued on anticoagulation.