SHM Converge Scientific Abstract ePoster Gallery-Clot in Transit With Pulmonary Embolism- Treat in Time

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This case describes a 70-year-old woman with vascular dementia and recent COVID-19 infection who was transferred from a nursing home with altered mental status, vomiting, and hypoxia. On arrival, she was hypotensive, tachycardic, and required vasopressor support. Initial evaluation showed leukocytosis, cholestatic liver injury, acute kidney injury, severe hyperglycemia, and atrial fibrillation with rapid ventricular response. She was intubated for worsening respiratory status and admitted to the ICU.<br /><br />Her hospital course revealed septic shock from suspected cholangitis, confirmed by abdominal imaging and treated with cholecystostomy, ERCP, antibiotics, and drainage of pus and sludge. Despite this, echocardiography on hospital day two identified a highly mobile right atrial thrombus “in transit” with right heart strain. CT angiography of the chest demonstrated large acute pulmonary emboli. A transesophageal echocardiogram later showed the thrombus arising from the vena cava, prolapsing through the tricuspid valve, and possibly crossing a patent foramen ovale into the left atrium, raising concern for systemic embolization.<br /><br />Because of the patient’s septic shock, presence of a PFO, and overall high procedural risk, an interdisciplinary team discussed catheter-based therapy, systemic thrombolysis, and anticoagulation. Given the patient’s dementia and family preference, the team chose anticoagulation and close observation rather than invasive clot retrieval or tPA. She improved clinically over five days and was discharged to her nursing home on oral rivaroxaban.<br /><br />This case highlights the high mortality risk of clot-in-transit with pulmonary embolism and the complexity of choosing treatment in unstable patients, especially those with recent COVID-19, which may contribute to a prothrombotic inflammatory state.

Asset Subtitle

Khushboo Singh

Meta Tag

Author List Aleesha Kainat, Anjana Chandrasekhara Pillai, Khushboo Singh, Tissa Bijoy George

Category Clinical Vignettes

Concept Clot-in-Transit

Concept Venous Thromboembolism

Concept Pulmonary Embolism

Concept Right Atrial Thrombus

Concept Patent Foramen Ovale

Distinguished Non-Finalist

Presenter Organization Upmc

Presenting Author Khushboo Singh

Track Adult

Keywords

right atrial thrombus

pulmonary embolism

septic shock

cholangitis

COVID-19

anticoagulation

patent foramen ovale

transesophageal echocardiogram

rivaroxaban

intensive care unit

Clot-in-Transit

Venous Thromboembolism

Pulmonary Embolism

Right Atrial Thrombus

Patent Foramen Ovale