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We report an extremely rare case of an extensive biatrial thrombus straddling a patent foramen ovale (PFO) extending into the bilateral ventricles in a patient presenting with an acute embolic stroke. Our patient further developed a massive saddle pulmonary embolus (PE) with haemodynamic instability during the course of his hospitalisation. The risks of pharmacological thrombolysis or surgical thrombectomy for PE in a haemodynamically unstable patient with recent embolic stroke posed a significant therapeutic dilemma. Ultimately, the decision was made to continue anticoagulation with unfractionated heparin followed by oral Coumadin. The patient responded well to therapy and at 1-month follow-up, a complete resolution of the thrombus was documented on transoesophageal echocardiogram with full clinical recovery of the patient.

Extensive biatrial thrombus straddling the patent foramen ovale and traversing into the left and right ventricle