A 61-year-old man was admitted for evaluation of progressive dyspnea several months after coronary artery bypass surgery. Ventilation-perfusion lung scanning revealed perfusion defects compatible with multiple pulmonary emboli. Transthoracic echocardiography was remarkable for normal left ventricular function, dilated right heart chambers, elevated pulmonary pressures, and a free-floating right atrial thrombus. Transesophageal echocardiography demonstrated free-floating right atrial thrombus with migration of the snakelike clot through a patent foramen ovale (Figure).
The patient's surgical risk for removal of the clot was increased by his prior surgery and elevated pulmonary pressures. Because of this, he was treated with a peripheral intravenous infusion of 100 mg of tissue plasminogen activator over 2 hours without a bolus. Repeat transthoracic echocardiography 4 hours after and transesophageal echocardiography 24 hours after initiation of thrombolytic therapy revealed no evidence of the thrombus and a dramatic improvement in right ventricular chamber size and pulmonary pressures. There was no evidence of systemic embolization, and the patient was discharged several days later on oral anticoagulation medication.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner, MC 4-265, Houston, TX 77030.
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