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.