Surgical Embolectomy for a Clot-in-Transit Located in a Patent Foramen Ovale: A Case Report

Pulmonary embolism (PE) is a serious and potentially life-threatening medical condition that arises when a blood clot, typically originating in the deep veins of the legs or pelvis, travels through the bloodstream and lodges in the pulmonary arteries. This obstruction can impede blood flow to the lungs, leading to complications. PEs are a critical manifestation of venous thromboembolism, a condition characterized by the formation of blood clots within veins. The consequences of PE can vary, ranging from mild respiratory distress to severe respiratory failure or cardiac arrest, depending on the size and location of the clot. Prompt diagnosis and intervention are crucial to mitigate associated life-threatening implications. Patent foramen ovale (PFO) is an abnormality characterized by the persistence of a small opening between the atria of the heart. During fetal development, this opening, known as the foramen ovale, allows blood to bypass the non-functioning lungs. Normally, the foramen ovale closes shortly after birth. However, when it fails to seal completely, a PFO occurs. It is a relatively common variation and is often asymptomatic. However, it has gained attention in the medical field due to its association with certain health issues, particularly paradoxical embolism. This occurs when a blood clot, typically formed in the venous system, passes through the PFO and travels to the arterial circulation, potentially causing complications such as a stroke. This case report adds to the literature and highlights the importance of recognizing concurrent PFO and PE. A 30-year-old female patient arrived at the emergency room experiencing sudden difficulty breathing and diaphoresis. The presenting vital signs demonstrated mild sinus tachycardia and tachypnea with an oxygen saturation of 95% on room air. A transesophageal echocardiogram (TEE) was performed, which confirmed a mass extending into the septum and crossing the PFO. Catheter-directed thrombectomy was deemed unsafe and the patient was transferred emergently to the operating room for sternotomy, pulmonary embolectomy, extraction of PE-in-transit, and PFO closure. Upon administration of general anesthesia, the patient experienced a significant decrease in blood pressure and oxygen saturation. A repeat TEE was performed and it revealed profound right heart dysfunction with an absence of the PE that had previously been lodged in the interatrial septum. Urgent bilateral pulmonary embolectomy was undertaken to extract the embolism in transit from the pulmonary artery. This case report highlights a PE-in-transit at the interatrial septum through a PFO following induction of positive pressure ventilation and anesthesia, resulting in a hemodynamic collapse. The benefits of surgical embolectomy over traditional catheter-guided thrombectomy are highlighted in this complex case of massive PE.