Extensive clot propagation involving the aorta and brachiocephalic artery: unusual consequence of paradoxical embolism

A 73-year old woman with factor V Leiden deficiency and a history of deep venous thrombosis ceased taking oral warfarin. She sustained a massive cerebral infarct following extensive paradoxical embolism involving the brachiocephalic artery and the aorta (Fig. 1A and B). Transoesophageal echo findings (Fig. 2A and B) can be viewed in Supplementary Videos 1 and 2. Supplementary material (Videos 1 and 2) is available at EJCTS online. Video 1: Transoesophageal echocardiogram showing a large free-floating luminal thrombus within the aortic arch. Video 2: Transoesophageal echocardiogram demonstrating a large patent foramen ovale and an aneurysmal interatrial septum with a right-to-left shunt.