the patient is a 46-year - old african american male with a history of stroke , diabetes , and hiv , who presented with a sudden onset shortness of breath , palpitations , and chest discomfort .
physical examination was unremarkable except for tachycardia and right - sided weakness associated with an episode of stroke 10 years earlier .
ct chest angiography demonstrated a large bilateral pulmonary embolism ( pe ) with straightening of the interventricular septum suggesting right heart strain ( fig .
right heart strain necessitated a transthoracic echocardiogram ( tte ) that showed a possible thrombus versus mass in both atria . to confirm the diagnosis ,
the tee showed a pfo with a large thrombus measuring 10 cm lodged in the pfo ( fig .
a tee with bubble study , which was done as part of the previous stroke workup , did not show any right - to - left shunt .
cardiac surgery was consulted for possible surgical removal of the thrombus and repair of the pfo . after a discussion of the risks and benefits of surgical versus medical management
a year later , follow - up tte did not show a pfo or any clot in the heart .
the mortality rate in cases of pe with thrombus in transit is very high ( 1 ) .
there is no general consensus about the best treatment for a thrombus entrapped in a pfo ( 2 ) .
because of the high risk of death from thrombus in transit , a cardiothoracic surgeon should be consulted immediately upon confirming the diagnosis ( 3 ) .
if the pfo is not repaired , the patient should remain on anticoagulation indefinitely ( 4 ) .
this case is also a reminder that a negative tee does not rule out the presence of a pfo ( 5 ) .
the authors have not received any funding or benefits from industry or elsewhere to conduct this study .
 in rare cases , thrombus in transit can be entrapped in a patent foramen ovale ( pfo ) . 
 a patient with this condition is at high risk of embolic stroke and death . 
 early diagnosis and treatment is essential to help prevent stroke and death in these cases . 
 there is no universal management guideline for this rare condition . 
 the decision between medical versus surgical treatment should be made individually for each patient . 
 we present a case of thrombus in transit entrapped in a pfo that was treated medically by lifelong anticoagulation . 
Case presentation
Discussion
Conflict of interest and funding