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To the Editor:
In the report published in your journal by Erkut and colleagues,1 “Entrapped Thrombus in a Patent Foramen Ovale,” two different therapies were suggested for entrapped or left-sided thrombus: thrombolytic and surgical treatment. We would like to report a third treatment option, which we successfully applied in a similar patient.
A 68-year-old woman presented at our emergency clinic with dyspnea, palpitations, acute-onset chest pain, and left-leg swelling. She had a history of chronic obstructive pulmonary disease and chronic atrial fibrillation. Doppler ultrasonography of the lower extremities revealed deep-vein thrombosis in the left leg. Transthoracic echocardiography showed normal systolic function, right atrial and right ventricular enlargement, and grade-2 tricuspid regurgitation. The pulmonary artery systolic pressure was estimated to be 55 mmHg. There was a mobile, multilobular mass in the left atrium, attached to the interatrial septum. For better delineation of the mass and atria, we performed transesophageal echocardiography (TEE): 2- and 3-dimensional TEE showed a 4 × 5-cm multilobular, homogeneously echogenic mobile mass attached to patent foramen ovale (Figs. 1 and and2).2). These findings were confirmed by TEE with contrast medium. No mass was seen on the right atrial side. It is likely that a thrombus from the right side dislodged, because the patient was diagnosed with pulmonary embolism by use of clinical and laboratory tests. We treated the patient with unfractionated heparin bolus and infusion, monitored with regular aPTT follow-up tests. Two days later, transthoracic echocardiography showed that the thrombus on the left side had disappeared (Fig. 3). The patient was discharged from the hospital on warfarin therapy.
It is possible that the interatrial septal mass was not seen on follow-up echocardiography because it had embolized to a peripheral location in the interim—this is always a risk. However, we do not believe that this occurred in our patient, because of her improved clinical picture. In the report by Erkut and colleagues,1 two different therapies were suggested.2,3 We recommend that heparin infusion be considered as a third therapeutic option, depending on the urgency of the clinical situation.