Intracardiac Thrombus-in-Transit Characterized on 3-Dimensional Transesophageal Echocardiography

Abstract

A 60-year-old woman presented with fever and shortness of breath of one week's duration. Physical examination disclosed a right-lower-quadrant abdominal mass and pretibial edema. A chest computed tomogram showed bilateral pulmonary embolism, and venous Doppler ultrasonographic imaging of the lower extremities revealed acute deep vein thrombosis (DVT) of the right common femoral vein. Abdominal ultrasonograms showed a large right ovarian mass. A 2-dimensional transthoracic echocardiogram (2D TTE) showed an echogenic mass in the atria. Two-dimensional transesophageal echocardiograms (TEE) revealed an aneurysmal interatrial septum and a large, mobile mass in the right atrium. The mass was in transit through a patent foramen ovale and extended into the left atrium ( Fig. 1). Three-dimensional (3D) TEE helped to characterize the mass as a thrombus-intransit that extended through the interatrial septum (Fig. 2). Upon sequential cropping of the images, echolucent components seen inside the mass were consistent with an intracardiac thrombus.1 The ovarian mass was found to be malignant. The patient was prescribed long-term anticoagulation. After 6 months, 2D TTE revealed complete resolution of the thrombus and no evidence of left-sided emboli. CommentThrombus-in-transit is rarely reported and is often associated with pulmonary embolism or paradoxical systemic embolism when an intracardiac shunt is present. In our patient, DVT associated with a hypercoagulable state of malignancy was thought to be responsible for the thrombus-in-transit and the pulmonary emboli.Thrombi-in-transit have almost exclusively been diagnosed with the use of echocardiography.2 Using 3D TEE enables the sequential sectioning of an intracardiac mass and inspection of its inner aspects from multiple angles. This in turn helps to establish a more accurate diagnosis and more specific therapeutic interventions. The most appropriate therapy for thrombus-in-transit has not been clearly defined; antico- Figure 1B. Images in Cardiovascular Medicine

Incremental Value of Three‐Dimensional Transesophageal Echocardiography over the Two‐Dimensional Technique in the Assessment of a Thrombus in Transit through a Patent Foramen Ovale

“…There are a few reports in the literature describing 3DTEE imaging findings in patients with a thrombus in transit . However, some of them do not allude to any additional information provided by 3DTEE over 2DTEE.…”

“…There are a few reports in the literature describing 3DTEE imaging findings in patients with a thrombus in transit . However, some of them do not allude to any additional information provided by 3DTEE over 2DTEE. In one additional report, it was stated that 3DTEE provided better spatial characterization of the structures involved and better defined the size and mobility of a thrombus in transit, but no specifics were given and no measurements provided for comparison with 2DTEE.…”

Paradoxical Thrombus ‘Caught in the Act’: Case Report and Review of the Literature

“…1 Paradoxical embolism is a rare finding, with only 13 cases published in the past 5 years (Table ). [2][3][4][5][6][7][8][9][10][11][12] Sequelae include pulmonary embolism and stroke, often with devastating outcomes. Management remains controversial.…”