4-6) A thrombus from the venous system into the right heart may easily cross into the left heart through a PFO if the right atrial pressure exceeds left atrial pressure, which can occur in the setting of pulmonary hypertension.2),4),6) Echocardiography, especially TEE, plays a main diagnostic tool in recognizing this potentially life-threatening, but treatable, condition.7) Patients with a right-to-left intracardiac shunt via a PFO, agitated saline contrast-enhanced Inhibitors,research,lifescience,medical TEE is helpful. Interatrial pressure gradient can

be reversed during cough or Valsalva maneuver. Cough test is known to be superior to Valsalva maneuver in the delineation of right to left shunt.8) Valsalva maneuver is contraindicated in patients with thrombus-in-transit

via PFO – the risk of another embolism. The best treatment for a pulmonary embolism with a thrombus straddled across PFO is Inhibitors,research,lifescience,medical unclear. Basically, the therapeutic options are cardiac surgery, thrombolysis, or anticoagulation with heparin, or a combination of all these treatments. Currently, surgical embolectomy and closure of PFO has been done as a preferred option.9-11) In our case, we decided the intravenous thrombolysis because of the patient’s missing thrombus, although fragmentation of the thrombus followed by pulmonary or systemic embolization may be a theoretical risk of this treatment. Some previous reports described Inhibitors,research,lifescience,medical anticoagulant Inhibitors,research,lifescience,medical therapy can be used as an alternative treatment in this condition. 4),12) We described a case of highly suspected paradoxical embolism with pulmonary embolism, in which a thrombus straddled and disappeared through PFO was observed in see more transesophageal echocardiography. In conclusion, thrombus-in-transit can be demonstrated by TEE in patients with pulmonary embolism and if detected, immediately treatment can prevent systemic embolism. Supplementary movie legends

Movie 1. Transesophageal echocardiography shows serpentine, hypermobile thrombus entraps in patent foramen ovale. Movie 2. Thrombus in transit is disappeared after involuntary cough. Inhibitors,research,lifescience,medical The tiny gap indicates the presence of patent foramen ovale. Movie 3. Color Doppler jet shows right to left shunt. Supplementary Material Supplementary movie 1 Click here to view.(32M, Parvulin avi) Supplementary movie 2 Click here to view.(30M, avi) Supplementary movie 3 Click here to view.(27M, avi)
In hypertensive patients, blood pressure (BP) usually fluctuates during the 24-hour circadian rhythm. Thus, the mean blood pressure values are 10-20% lower during the night, compared to daytime measurement.1) This condition is called “the dipper” change. In contrast, non-dippers are defined as the patients without these diurnal fluctuations in blood pressure.2),3) The 24-hour ambulatory blood pressure (ABP) monitoring is widely used for the evaluation of diurnal fluctuation of BP.