Cardioembolic stroke caused by bi-atrial thrombus and treated with intracardiac thrombectomy; a case report

Background: Right atrium thrombus is labeled as thrombi in transit. It either progresses to the pulmonary arteries causing significant pulmonary embolism, or it straddles through Foramen Ovale leading to impending paradoxical embolism causing ischemic strokes. We are presenting a rare case of right atrial thrombi straddling through PFO and causing embolic ischemic stroke and multiple PEs. Results: A 79 years old male with history of coronary artery disease s/p CABG surgery who presented with acute onset altered mental status and left side weakness. CT angiogram of the head showed occlusion of the distal right posterior cerebral artery PCA. Brain MRI confirmed the acute right occipital lobar infarct. Transthoracic and transesophageal echocardiogram confirmed the right atrium, 5.5 x 0.7 cm serpentine thrombus extending across PFO to the left atrium and relapsing through the mitral valve. CT PE showed pulmonary emboli in the proximal left lower pulmonary artery and the segmental and subsegmental branches. This raised the concern for anterograde propagation of the right atrial thrombus into the pulmonary artery. The patient remained hemodynamically stable with neurological deficit of left homonymous hemianopsia and left ataxia. Given the size and burden of the thrombus and the risk of further embolization, patient was started on IV anticoagulation. He underwent emergent percutaneous right atrial aspiration embolectomy followed by endovascular closure of the PFO. The patient improved without further strokes. Conclusions: Treatment of bi-atrial intra-cardiac thrombus causing both systematic and pulmonary embolization is not yet standardized. However, due to high risk of systematic embolization especially embolic stroke, acute intervention with embolectomy is favored. PFO closure has been shown in multiple clinical trials to decrease risk of paradoxical stroke. This is a case of multi-systemic embolization of the bi-atrial thrombus showing favored outcome with immediate intervention with concurrent anticoagulation