title: Crossing atrial thrombus in a patient with recurrent pulmonary embolism.
abstract: OBJECTIVE
  To report the detection of a thrombus entrapped in a patent foramen ovale by echocardiography in a patient with recurrent pulmonary embolism.
  
  
  METHODS
  Case report.
  
  
  METHODS
  Intensive care unit of a university hospital.
  
  
  METHODS
  A 62-yr-old man with initial deep venous thrombosis and recurrent minor pulmonary embolism followed by a severe embolic event with transitory hemiparesis 10 days after prostatectomy.
  
  
  METHODS
  Systemic anticoagulation, surgical removal of a crossing atrial thrombus, closure of a patent foramen ovale, and venous thrombectomy.
  
  
  RESULTS
  Transesophageal echocardiography revealed a large thrombus entrapped in a patent foramen ovale with portions in all four heart chambers. Intraoperatively, a 19-cm-long thrombus, shaped like the pelvic veins, was found. The patient was successfully weaned from cardiopulmonary bypass, requiring temporary positive inotropic support because of right ventricular dysfunction. Within 24 hrs of the operation, the patient was discharged to the intermediate care unit.
  
  
  CONCLUSIONS
  Recurrent pulmonary embolism can potentially result in paradoxic embolism in patients with a patent foramen ovale. In such patients, it may be crucial to monitor right ventricular function and exclude right-to-left shunts by transesophageal echocardiography, regardless of clinical symptoms. The patent foramen ovale should be closed. This case emphasizes an important indication for transesophageal echocardiography in critically ill patients.
authors.affiliation: Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Münster, Münster, Germany. stw@uni-muenster.de
authors.forename: Stefan P
authors.initials: SP
authors.lastname: Wirtz
authors.forename: Christoph
authors.initials: C
authors.lastname: Schmidt
authors.forename: Dieter
authors.initials: D
authors.lastname: Hammel
authors.forename: Andreas
authors.initials: A
authors.lastname: Hoffmeier
authors.forename: Elmar
authors.initials: E
authors.lastname: Berendes
mesh_terms: D003937:Diagnosis, Differential; D017548:Echocardiography, Transesophageal; D006325:Heart Atria / Q000000981:diagnostic imaging / Q000473:pathology*; D006344:Heart Septal Defects, Atrial / Q000000981:diagnostic imaging / Q000473:pathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000150:complications; D012008:Recurrence; D013927:Thrombosis / Q000150:complications / Q000175:diagnosis*