Therapeutic Dilemmas Arising From a Serpentine Thrombus Across a Patent Foramen Ovale in a Patient With Dilated Cardiomyopathy.

A thrombus straddling a patent foramen ovale (TSPFO) is a rare condition that presents significant health risks, including stroke or myocardial infarction, and can be life-threatening if not promptly addressed. We report the case of a 42-year-old female with morbid obesity who presented with sudden shortness of breath due to a bilateral pulmonary embolism. Imaging revealed a thrombus extending from the right atrium to the left atrium through the patent foramen ovale (PFO). Further evaluation showed a new diagnosis of dilated cardiomyopathy, resulting in biventricular heart failure, confirmed by cardiac MRI. Given her relatively stable hemodynamics during her hospital stay, the patient was successfully treated with anticoagulation, leading to complete resolution of the clot, thus avoiding the need for thrombolysis or surgical intervention. In managing TSPFO, treatment decisions should be based on factors such as hemodynamic stability, coexisting conditions, the acute nature of the diagnosis, and the risk of embolism. While some literature reviews and case studies suggest that surgery may lower the risk of complications compared to thrombolysis or conservative medical management, the lack of level I and II evidence highlights the need for an individualized, evidence-informed approach to effective risk management.