A 58-year-old male presented with a hemodynamically significant pulmonary embolism.Computed tomography angiogram revealed a saddle embolus in the main pulmonary artery Doormat Couple Card with extensive clot burden affecting all lobes and right heart strain.Transthoracic echocardiogram displayed a dilated right ventricle with reduced systolic function.The patient was scheduled for pulmonary embolectomy.
The intraoperative transesophageal echocardiogram (TEE) demonstrated a mobile left atrial thrombus that was missed on previous imaging.After removal of Sponge Blender the thrombi, TEE showed a patent foramen ovale (PFO).The left atrial thrombus passed across the PFO secondary to increased right heart and pulmonary pressures.