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A 74-year-old woman was admitted in the emergency department in November 2018 for dyspnea, sudden chest pain and hemodynamic instability. Se had a previous history of pelvic fracture in September 2018, complicated with subdural hematoma secondary to therapeutic anticoagulation that wassurgically managed in October 2018. A through pulmonary arteries CT revealed massive pulmonary thromboembolism with right ventricle overload and pulmonary infarction. Because of history of cerebral hemorrhage, fibrinolytic treatment was ruled out and surgical approach of pulmonary embolism was decided. An intraoperative transesophageal echocardiogram demonstrates a thrombus in the right atrium (Figure 1A, yellow arrow), with invasion through the interatrial septum through a patent foramen ovale (Figure 1B, yellow arrow) with extension to mitral valve plane in the left ventricle (Figure 1C, yellow arrow). "Transit thrombus" was removed, patent foramen ovale was closed and bilateral pulmonary embolectomy was performed. In postoperative transesophageal echocardiography, no residual thrombus in cardiac chambers was seen and the closure of the foramen ovale was checked (Figure 1D). During the postoperative period, the patient presented cardiac tamponade, treated with pericardial drainage. Once this complication was overcome, the evolution was satisfactory and the patient could be discharged. This case demonstrates that performing a transesophageal echocardiogram before a surgical embolectomy in the setting of pulmonary embolism is essential. It allows detect the presence of cardiac thrombi, assess the interatrial septum integrity (where the CT has limitations), and allows to guide the surgical treatment. Abstract P1455 Figure.

P1455 Succesfully surgical management of "transit thrombus"