Thrombus in transit: traveling from the inferior vena cava to the left ventricle

A 54-year-old previously healthy woman presented with shortness of breath following a long car journey. The patient was found to have massive pulmonary embolism on computed tomography (CT) angiography (Fig. 1). Transthoracic echocardiography showed a dilated and poor-functioning right ventricle with a snake-like large mobile thrombus extending from the inferior vena cava (Video 1) to the right atrium and prolapsing to the right ventricle (Video 2) across the tricuspid orifice with each diastole (Video 3). The thrombus was entrapped in the patent foramen ovale (PFO) and extended to the left atrium, protruding into the left ventricle through the mitral valve (Video 4). There was no sign of peripheral emboli. The patient underwent urgent surgical embolectomy. Post-operative course was complicated with a large pericardial effusion that required drainage. The patient was well at 6 months follow-up.