Case Report: Embolus in transit vs. in situ PFO thrombus

A crossing patent foramen ovale (PFO) thrombus is a thrombus that straddles both atria through a PFO, also called a transseptal thrombus or an impending paradoxical embolism. Although rare, this condition represents a highly critical clinical emergency. Clinically, such thrombi are usually classified as primary intracardiac (<i>in situ</i>) thrombosis or emboli in transit from the venous system. We report two contrasting cases of a thrombus straddling the foramen ovale documented with high-quality multimodality imaging and serial transesophageal echocardiography (TEE) during follow-up. Case 1 involved a 21-year-old man who presented with sudden severe dyspnea, profuse sweating, and transient loss of consciousness after a long-distance train journey. TEE demonstrated a large, highly mobile thrombus straddling the PFO with right heart enlargement and pulmonary hypertension, and CT pulmonary angiography (CTPA) confirmed extensive pulmonary embolism. During emergency surgery, thrombi were removed from the right atrium, PFO, left atrium, and pulmonary arteries with concomitant PFO closure. Subsequent targeted genetic testing revealed a heterozygous SERPINC1 nonsense variant classified as likely pathogenic for antithrombin deficiency, suggesting underlying hereditary thrombophilia. Case 2 involved a 75-year-old woman with hypertension and persistent atrial fibrillation who underwent TEE screening before planned catheter ablation, which revealed a small, relatively fixed thrombus confined to the PFO tunnel. She was managed conservatively with 20 mg of rivaroxaban once daily, and serial TEE at 54 and 141 days revealed progressive thrombus regression without peripheral embolic events. These cases illustrate typical imaging features and clinical contexts that help distinguish an embolus in transit from a presumed <i>in situ</i> PFO thrombus and show how careful determination of the thrombus origin and nature can guide individualized management, help prevent catastrophic embolic events, and improve patient outcomes.