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This is a case report of a 35 young man with Klinefelter Syndrome presented breathlessness, palpitations and chest pain. It shows a rare case of a thrombus located through the PFO, in patient with pulmonary and paradoxical embolism, which takes back to exciting hypothesis on thrombus growth. A thrombus, which has grown 'in situ' or trapped through the patent foramen ovale, may be a cause of relapsing pulmonary or systemic embolism during anticoagulation therapy.  To prevent recurrent paradoxical embolism, percutaneous closure of PFO is recommended, but in this case, thrombus was trapped through the PFO and the patient was referred to the surgeon.  We believe that under these circumstances the clinician should be informed of the presence of PFO in critical pulmonary embolism; this case points out the key role of TEE to face a diagnostic and therapeutic scenarios.

Pulmonary embolism and patent foramen ovale thrombosis: the key role of TEE