Pulmonary Embolism In-Transit Crossing the Mitral and Aortic Valve

Hemodynamically significant pulmonary embolisms (PE) in the pulmonary artery or those crossing a patent foramen ovale (PFO) can become life-threatening emergencies requiring immediate removal. While cases of surgical management for a PE crossing a PFO have been reported, there are no documented cases of a PE extending across both the mitral and aortic valves. A 38-year-old female with a medical history of obesity, depression, and thalassemia minor was transferred from an outside hospital with hemodynamic compromise due to a large PE. Transesophageal echocardiography (TEE) revealed a PE crossing the PFO, extending across the mitral valve, and traversing the aortic valve into the ascending aorta. Cardiopulmonary bypass (CPB) was initiated using standard aortic cannulation distal to the known clot, along with bicaval venous cannulation. The heart was arrested, and the right and left atria were opened in a transeptal fashion. The clot, which extended from the PFO through the mitral and aortic valves, was identified and removed en bloc. A small aortotomy was performed, confirming a clear aorta. An additional clot was found in the right atrium crossing the tricuspid valve and was subsequently removed. Finally, the pulmonary artery was opened, and the bulk of the clot burden was extracted, completing the embolectomy. The patient was successfully weaned from CPB without complications and was extubated within 24 h post-surgery. She underwent inferior vena cava filter placement and was discharged on post-operative day seven. Extensive pulmonary emboli are life-threatening emergencies that require immediate intervention. This study presents an extensive clot burden crossing the PFO, mitral valve, and aortic valve. Prompt surgical intervention is crucial to preventing severe complications such as stroke, myocardial infarction, respiratory failure, death, and long-term sequelae, including pulmonary hypertension and future strokes.