case_images: PMC6521405_01
case_images: 12 lead ECG on admission showing sinus rhythm 95 bpm with S1Q3T3 pattern (prominent S wave in lead I, Q wave and inverted T wave in lead III, green arrows).
case_images: CRIPU2019-5747598.001.jpg
case_images: PMC6521405_01_CRIPU2019-5747598.001.jpg
case_images: fig1
case_images: Troponin I level was normal, BNP was elevated at 704 pg/ml (reference 0-100 pg/ml), 12 lead ECG showed sinus rhythm 95 bpm with S1Q3T3 pattern (Figure 1): Chest X-ray was unremarkable.
case_images: CTPA showing saddle PE (a), intracardiac thrombus extending from RA to LA through PFO (b) and further prolapsing into the left ventricle through mitral valve leaflets (c): all axial reconstruction. The same clot in sagittal view ((d), inside the red circle) and coronal view (e). RV enlargement relative to LV compressing the LV in characteristic "D shaped" pattern ((f), double arrows) all consistent with RV strain.
case_images: CRIPU2019-5747598.002.jpg
case_images: PMC6521405_01_CRIPU2019-5747598.002.jpg
case_images: fig2
case_images: Wells' score was 7.5 (3 points for clinical signs and symptoms of deep vein thrombosis, 3 points of PE being the most likely diagnosis, and 1.5 points for heart rate > 100 bpm) rendering high chance of PE; therefore, CT pulmonary angiogram (CTPA) was performed (Figure 2).
case_images: Echocardiography: (a) TTE apical four-chamber view demonstrating elongated LA thrombus (red arrows) prolapsing through PFO and LA into the LV during the diastole. Green arrows depict mitral valve leaflets. (b) The same clot is clearly visualized on TEE attached to interatrial septum. Yellow arrow depicts the location of PFO. (c) TTE subcostal view enlarged right heart chambers exceeding their left counterparts in size.
case_images: CRIPU2019-5747598.003.jpg
case_images: PMC6521405_01_CRIPU2019-5747598.003.jpg
case_images: fig3
case_images: TTE (Figure 3) showed a large mobile mass straddling the interatrial septum with elements in both atria, extending to and past the mitral valve and prolapsing into the left ventricle during diastole. TTE findings (Figure 3): because of the presence of an unstable extensive lower extremity venous thrombus an inferior vena cava filter was also placed. The patient tolerated the surgery well and was discharged from the hospital on oral anticoagulation with warfarin.
case_images: Photographs from surgical thrombectomy. Saddle pulmonary embolus was extracted from the pulmonary artery. The embolus that extended to all visualized segments of the branch pulmonary arteries was removed as well. The thrombus that was straddling the PFO was also removed en bloc. The PFO was surgically closed.
case_images: CRIPU2019-5747598.004.jpg
case_images: PMC6521405_01_CRIPU2019-5747598.004.jpg
case_images: fig4
case_images: Because of large clot burden as well as impending paradoxical embolization, the patient underwent emergent open pulmonary embolectomy, removal of right and left atrial thrombi, and PFO closure (Figure 4).